4.1: Panic Disorder

Section Learning Objectives

• Describe how panic disorder presents itself.
• Describe the epidemiology of panic disorder.
• Indicate which disorders are commonly comorbid with panic disorder.
• Describe the treatment options for panic disorder.

Clinical Description

Panic disorder consists of a series of recurrent, unexpected panic attacks coupled with the fear of future panic attacks. A panic attack is defined as a sudden or abrupt surge or fear or impending doom along with at least four physical or cognitive symptoms (listed below). The symptoms generally peak within a few minutes, although it seems much longer for the individual experiencing the panic attack.

There are two key components to panic disorder—the attacks are unexpected meaning there is nothing that triggers them, and they are recurrent meaning they occur multiple times. Because these panic attacks occur frequently and essentially “out of the blue,” they cause significant worry or anxiety in the individual as they are unsure of when the next attack will occur. In some individuals, significant behavioral changes such as fear of leaving their home or attending large events occur as the individual is fearful an attack will happen in one of these situations, causing embarrassment. Additionally, individuals report worry that other’s will think they are “going crazy” or losing control if they were to observe an individual experiencing a panic attack. Occasionally, an additional diagnosis of agoraphobia is given to an individual with panic disorder if their behaviors meet diagnostic criteria for this disorder as well (see more below).

The frequency and intensity of these panic attacks vary widely among individuals. Some people report panic attacks occurring once a week for months on end, others report more frequent attacks multiple times a day, but then experience weeks or months without any attacks. The intensity of symptoms also varies among individuals, with some individuals reporting experiencing nearly all 14 symptoms and others only reporting the minimum 4 required for the diagnosis. Furthermore, individuals report variability within their own panic attack symptoms, with some panic attacks presenting with more symptoms than others. It should be noted that at this time, there is no identifying information (i.e. demographic information) to suggest why some individuals experience panic attacks more frequently or more severe than others.

Epidemiology

Prevalence rates for panic disorder are estimated at around 2-3% in adults and adolescents. Higher rates of panic disorder are found in American Indians and non-Latino whites. Females are more commonly diagnosed than males with a 2:1 diagnosis rate—this gender discrepancy is seen throughout the lifespan. Although panic disorder can occur in young children, it is generally not observed in individuals younger than 14 years of age.

Comorbidity

Panic disorder rarely occurs in isolation, as many individuals also report symptoms of other anxiety disorders, major depression, and substance abuse. There is mixed evidence as to whether panic disorder precedes other comorbid psychological disorders—estimates suggest that 1/3 of individuals with panic disorder will experience depressive symptoms prior to panic symptoms whereas the remaining 2/3 will experience depressive symptoms concurrently or after the onset of panic disorder (APA, 2013).

Unlike some of the other anxiety disorders, there is a high comorbid diagnosis with general medical symptoms. More specifically, individuals with panic disorder are more likely to report somatic symptoms such as dizziness, cardiac arrhythmias, asthma, irritable bowel syndrome, and hyperthyroidism (APA, 2013). The relationship between panic symptoms and somatic symptoms is unclear; however, there does not appear to be a direct medical cause between the two.

Treatment

Cognitive Behavioral Therapy (CBT) 

CBT is the most effective treatment option for individuals with panic disorder as the focus is on correcting misinterpretations of bodily sensations (Craske & Barlow, 2014). Nearly 80 percent of people with panic disorder report complete remission of symptoms after mastering the following five components of CBT for panic disorder (Craske & Barlow, 2014).

1. Psychoeducation. Treatment begins by educating the client on the nature of panic disorder, the underlying causes of panic disorder, as well as the mechanisms that maintain the disorder such as the physical, cognitive, and behavioral response systems (Craske & Barlow, 2014). This part of treatment is fundamental in correcting any myths or misconceptions about panic symptoms, as they often contribute to the exacerbation of panic symptoms.
2. Self-monitoring. Self-monitoring, or the awareness of self-observation, is essential to the CBT treatment process for panic disorder. In this part of treatment, the individual is taught to identify the physiological cues immediately leading up to and during a panic attack.  The client is then encouraged to identify and document/record the thoughts and behaviors associated with these physiological symptoms. By bringing awareness to the symptoms, as well as the relationship between physical arousal and cognitive/behavioral responses, the client is learning the fundamental processes in which they can manage their panic symptoms (Craske & Barlow, 2014).
3. Relaxation training. Prior to engaging in exposure training, the individual must learn a relaxation technique to apply during the onset of panic attacks. While breathing training was once included as the relaxation training technique of choice for panic disorder, due to the high report of hyperventilation during panic attacks more recent research has failed to support this technique as effective in the use of panic disorder (Schmidt et al., 2000). Findings suggest that breathing retraining is more commonly misused as a means for avoiding physical symptoms as opposed to an effective physiological response to stress (Craske & Barlow, 2014). To replace the breathing retraining, Craske & Barlow (2014) suggest progressive muscle relaxation (PMR). In PMR, the client learns to tense and relax various large muscle groups throughout the body. Generally speaking, the client is encouraged to start at either the head or the feet, and gradually work their way up through the entire body, holding the tension for roughly 10 seconds before relaxing. The theory behind PMR is that in tensing the muscles for a prolonged period of time, the individual exhausts those muscles, forcing them (and eventually) the entire body to engage in relaxation (McCallie, Blum, & Hood, 2006).
4. Cognitive restructuring. Cognitive restructuring, or the ability to recognize cognitive errors and replace them with alternate, more appropriate thoughts, is likely the most powerful part of CBT treatment for panic disorder, aside from the exposure part. Cognitive restructuring involves identifying the role of thoughts in generating and maintaining emotions. The clinician encourages the individual to view these thoughts as “hypotheses” as opposed to facts, which allows the thoughts to be questioned and challenged. This is where the detailed recordings in the self-monitoring section of treatment are helpful. By discussing specifically what the client has recorded for the relationship between physiological arousal and thoughts/behaviors, the clinician is able to help the individual restructure the maladaptive thought processes to more positive thought processes which in return, helps to reduce fear and anxiety.
5. Exposure. Next, the client is encouraged to engage in a variety of exposure techniques such as in vivo exposure and interoceptive exposure, while also incorporating the cognitive restructuring and relaxation techniques previously learned in efforts to reduce and eliminate ongoing distress. Interoceptive exposure involves inducing panic specific symptoms to the individual repeatedly, for a prolonged time period, so that maladaptive thoughts about the sensations can be disconfirmed and conditional anxiety responses are extinguished (Craske & Barlow, 2014). Some examples of these exposure techniques are spinning a client repeatedly in a chair to induce dizziness and breathing in a paper bag to induce hyperventilation. These treatment approaches can be presented in a gradual manner; however, the client must endure the physiological sensations for at least 30 seconds to 1 minute to ensure adequate time for applying cognitive strategies to misappraisal of cognitive symptoms (Craske & Barlow, 2014). Interoceptive exposure is continued both in and outside of treatment until panic symptoms remit. Over time, the habituation of fear within an exposure session will ultimately lead to habituation across treatment, which leads to long-term remission of panic symptoms (Foa & McNally, 1996).  Occasionally, panic symptoms will return in individuals who report complete remission of panic disorder. Follow-up booster sessions reviewing the steps above is generally effective in eliminating symptoms again.

Pharmacological Interventions 

According to Craske & Barlow (2014), nearly half of people with panic disorder present to psychotherapy already on medication, likely prescribed by their primary care physician. Some researchers argue that anti-anxiety medications impede the progress of CBT treatment as the individual is not able to fully experience the physiological sensations during exposure sessions, thus limiting their ability to modify maladaptive thoughts maintaining the panic symptoms. Results from large clinical trials suggest no advantage during or immediately after treatment of combining CBT and medication (Craske & Barlow, 2014). Additionally, when medications were discontinued post-treatment, the CBT+ medication groups fared worse than the CBT treatment alone groups, thus supporting the theory that immersion in interoceptive exposure is limited by the use of medication. Therefore, it is suggested that medications are reserved for those who do not respond to CBT therapy alone (Kampman, Keijers, Hoogduin & Hendriks, 2002).