Introduction & Definitions
The experience of a panic attack is one of the most common reasons an individual seeks psychiatric care. Before we begin our discussion, let’s define some terms:
Panic Attack: A panic attack is an acute episode of intense fear characterized by sudden onset and typically lasting a few minutes to an hour. Most symptoms peak within 10 minutes. Commonly, individuals experience somatic symptoms such as palpitations, sweating, trembling or shaking, sensations of shortness of breath, feeling of choking, chest pain or discomfort, nausea or abdominal distress, feeling dizzy, derealization, or depersonalization.
Panic Disorder: Panic disorder is defined by experiencing recurrent panic attacks and at least one of the following: continual worry about future attacks, worry about the potential implications and/or consequences of attacks (eg, cardiac problems, “going crazy,” or losing control), and maladaptive behavior changes seeking to avoid or escape future attacks.
Epidemiology
Data suggests that the lifetime prevalence of panic disorder in the United States among adults is somewhere around 4.7% (Kessler et al., 2005)). This means that over 12 million people will meet the diagnostic criteria for panic disorder at some point in their lives. The typical age of onset for panic disorder is 24 years of age. When considering panic attacks vs. panic disorder, over 33% of individuals will experience a panic attack in their lifetime (Katon et al., 1987; Kessler et al., 2006).
Pathogenesis
As with many psychiatric disorders, the development of panic disorder is best conceptualized using the stress-vulnerability model. This model posits that each individual has a unique vulnerability (ie, predisposition) to the development of panic disorder. This vulnerability interacts with an individuals life stressors, resulting in precipitating symptomatology. Factors that influence one’s vulnerability or predisposition to panic disorder include, but are not limited to, personality traits, genetics, childhood stressors, and neurobiological factors.
Genetic Factors: Evidence suggests that there is a genetic component to panic disorder and researchers have implicated multiple genes and their varied expressions. Twin studies have found higher rates of concordance among monozygotic twins vs. dizygotic twins, suggesting a heritability of around 40% (Torgersen, 1983). Further, first-degree relatives of individuals with panic disorder have been found to have higher rates of panic disorder when compared to relatives of individuals with major depressive disorder and controls (Goldstein et al., 1994).
Neurobiological Factors: Historically, most research investigating the neurobiology of panic disorder focused on the monoamine hypothesis, implicating neurotransmitters such as norepinephrine, GABA, and serotonin. However, recent investigation has centered around areas of the hypothalamus and amygdala and their relative hyper-excitability (Gorman, Kent, Sullivan, and Coplan, 2000).
Psychosocial Factors: Finally, it is important to consider the amalgamation of psychosocial factors that can influence the development of panic disorder. Commonly, panic attacks coincide with life stressors and studies have found a link between the occurrence of panic attacks and the loss of loved ones, physical illnesses, and social distress. Childhood adversity, particularly physical, emotional, or sexual abuse, has also been found in to increase proclivity for panic attacks and development of panic disorder.
Clinical Manifestations
Panic attacks themselves are not a diagnosable disorder. It is only when one’s panic attacks meet criteria for panic disorder that an individual qualifies for a psychiatric diagnosis. As such, a panic attack can occur in the context of various medical or psychiatric illnesses.
DSM-V Diagnostic Criteria for Panic Disorder (F41.0)
A. Recurrent unexpected panic attacks.
A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur. Note: The abrupt surge can occur from a calm state or an anxious state.
- Palpitations, pounding heart, or accelerated heart rate.
- Sweating.
- Trembling or shaking.
- Sensations of shortness of breath or smothering.
- Feelings of choking.
- Chest pain or discomfort.
- Nausea or abdominal distress.
- Feeling dizzy, unsteady, light-headed, or faint.
- Chills or heat sensations.
- Paresthesias (numbness or tingling sensations).
- Derealization (feelings of unreality) or depersonalization (being detached from oneself).
- Fear of losing control or “going crazy.”
- Fear of dying.
Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms.
B. At least one of the attacks has been followed by 1 month (or more) of one or both of the following:
- Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, “going crazy”).
- A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations).
C. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary disorders).
D. The disturbance is not better explained by another mental disorder (e.g., the panic attacks do not occur only in response to feared social situations, as in social anxiety disorder: in response to circumscribed phobic objects or situations, as in specific phobia: in response to obsessions, as in obsessive-compulsive disorder: in response to reminders of traumatic events, as in posttraumatic stress disorder: or in response to separation from attachment figures, as in separation anxiety disorder).
Conclusion
In this article we defined panic attacks and panic disorders, discussed the epidemiology and pathogesnis, as well as outlined the clinical manifestations of panic disorder according to the DSM-V.
What’s Next?
In next month’s article we’ll discuss the most effective treatments for panic disorder.
References
Goldstein, R. B., Weissman, M. M., Adams, P. B., Horwath, E., Lish, J. D., Charney, D., Woods, S. W., Sobin, C., & Wickramaratne, P. J. (1994). Psychiatric disorders in relatives of probands with panic disorder and/or major depression. Archives of General Psychiatry, 51(5), 383–394. https://doi.org/10.1001/archpsyc.1994.03950050043005
Gorman, J. M., Kent, J. M., Sullivan, G. M., & Coplan, J. D. (2000). Neuroanatomical hypothesis of panic disorder, revised. The American Journal of Psychiatry, 157(4), 493–505. https://doi.org/10.1176/appi.ajp.157.4.493
Katon, W., Vitaliano, P. P., Russo, J., Jones, M., & Anderson, K. (1987). Panic disorder. Spectrum of severity and somatization. The Journal of Nervous and Mental Disease, 175(1), 12–19.
Kessler, R. C., Chiu, W. T., Demler, O., Merikangas, K. R., & Walters, E. E. (2005). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 617–627. https://doi.org/10.1001/archpsyc.62.6.617
Kessler, R. C., Chiu, W. T., Jin, R., Ruscio, A. M., Shear, K., & Walters, E. E. (2006). The epidemiology of panic attacks, panic disorder, and agoraphobia in the National Comorbidity Survey Replication. Archives of General Psychiatry, 63(4), 415–424. https://doi.org/10.1001/archpsyc.63.4.415
Torgersen S. (1983). Genetic factors in anxiety disorders. Archives of General Psychiatry, 40(10), 1085–1089. https://doi.org/10.1001/archpsyc.1983.01790090047007
J. Hennessy