Panic Disorder

What Causes Panic Disorder?

Doctors and researchers have not yet determined exactly what causes panic attacks and panic disorder, but a lengthy list of risk factors seems to increase an individual’s likelihood of developing the condition.

• Genetic Predisposition. People with a family history of panic disorder are significantly more likely to develop the condition than are people with no family history. Studies of identical twins have shown a heritability rate of as much as 40%, strongly suggesting a genetic component to the disorder’s development.
• Major stress. Major life events that cause stress may cause an onset of panic attacks. These events may include a divorce, death of a loved one, a child’s birth, trauma or injury, or unemployment.
• Sensitive temperament. Research suggests that those who are particularly sensitive to stressful situations are more likely to be susceptible to panic disorder.
• Substance use. Excessive consumption of substances such as caffeine or tobacco may increase the risk of panic attacks.
• History of abuse. People with a history of childhood physical or sexual abuse are also at increased risk of developing panic disorder.

Is Panic Disorder Hereditary?

There is strong evidence to suggest that panic disorder has some degree of heritability, and a genetic component in the development of the condition is very likely. However, environmental factors also play a significant role, and a specific genetic mechanism that produces the disorder has not been identified.

• In studies of families in which panic disorder is present, researchers have found a rate of development of the condition of 10% among those with a first-degree relative (a parent, child, or sibling) with the disorder. In the control groups, the rate was only 2.1%.
• Studies of identical twins have shown a heritability rate of between 30% and 40%. Such a high rate suggests that a genetic link is highly likely.
• In general, research has not identified a single gene that is linked to the disorder.

How Is Panic Disorder Detected?

Panic disorder most often sets in during adulthood, with most people experiencing their first panic attacks after the age of 20. Panic attacks and panic disorder are not entirely uncommon in children and adolescents, however. The early signs of the condition are often misdiagnosed, and adolescent sufferers sometimes don’t get appropriate treatment until the disorder has caused severe disruption to their lives. Given that treatment is very often successful at controlling panic attacks, early detection and proper diagnosis can prevent the disorder from severely impacting the sufferer’s life.

Potential early signs of panic disorder in young people include:

• Separation anxiety, or a fear of leaving home
• Disinterest in or a fear of going to school
• Decline in grades
• Withdrawal from social activities
• Depression or a persistent low mood
• Panic attack symptoms (racing heart, sweating, etc.) with no discernible physical cause
• Substance abuse

Panic disorder is generally easier to diagnose in adults, but recognizing early symptoms in conjunction with risk factors can help speed the diagnosis, treatment, and recovery paths.

Early signs and risk factors for panic disorder in adults include:

• Sudden, unexpected feelings of fear without an apparent cause
• Physical symptoms such as elevated heart rate, sweating, trembling, dizziness, chills, etc.
• Growing fear of specific situations such as crowded places
• Persistent fear of having another panic attack
• Avoidance of situations that might cause a panic attack
• Problems at work or in school because of changes in behavior

How Is Panic Disorder Diagnosed?

The process of diagnosing panic disorder begins with a physical assessment followed by a psychological assessment. Because the symptoms of panic attacks are often overtly physical, it is essential to rule out other medical conditions that could be causing the symptoms. Only after these potential physical conditions have been ruled out will the diagnostic process move on to possible psychological causes.

Diagnostic steps may include:

• A physical exam. This exam will be aimed at ruling out physical conditions that could be causing the symptoms.
• Blood and laboratory tests. These tests will look at the patient’s blood chemistry for thyroid function, electrolyte imbalances, anemia, chronic infection, cancer, or other underlying conditions. Screenings for drugs and alcohol may also be conducted to rule out symptoms caused by substance abuse. An electrocardiogram (ECG) may also be administered to check for problems with heart function.
• Psychological assessments. These assessments may take the form of questionnaires or talk sessions with a mental health professional to assess the patient’s mood, mental state, and mental health history. Family members or caregivers may also be asked to participate in these assessments.

The psychological assessment results will be compared to the diagnostic criteria for panic disorder in the Diagnostic and Statistical Manual of Mental Disorders. A mental health professional will look for these indications of panic disorder:

• Recurrent and unexpected panic attacks, followed by at least a month of one or more of the following:
• Persistent worry about the occurrence of another attack
• Worry about the consequences of an attack
• Significant change in behavior as a result of the attacks

How Is Panic Disorder Treated?

Given the proper treatment, many people diagnosed with panic disorder can substantially control the occurrence of panic attacks or eliminate them entirely. Treatment of the condition usually involves psychotherapy, medications, or both. The exact course of treatment prescribed in each case depends on the patient’s history and the severity and frequency of the panic attacks.

Medication

Several different medications may be used to treat and manage the symptoms of panic disorder. Individual medication plans depend on the patient’s preference, the patient’s responsiveness to treatments, the specific symptoms being experienced, and the severity of the symptoms.

• Selective serotonin reuptake inhibitors (SSRIs). These drugs work by increasing the levels of serotonin, a neurotransmitter chemical in the brain. SSRIs used to treat panic disorder include fluoxetine, paroxetine, and sertraline.
• Serotonin-norepinephrine reuptake inhibitors (SNRIs). These drugs work similarly to SSRIs in that they increase serotonin levels, but they also increase the level of norepinephrine, another neurotransmitter. The SNRI venlafaxine is approved for the treatment of panic disorder.
• Benzodiazepines. These drugs are used to treat anxiety, and they can help treat the symptoms of panic attacks. Benzodiazepines act more quickly than antidepressants, which typically take at least a week to have any effect, but patients may develop a resistance to benzodiazepines if they’re taken for an extended time. Alprazolam and clonazepam are benzodiazepines commonly prescribed for panic disorder.
• Beta-blockers. These drugs are commonly used to treat high blood pressure, but they can effectively control the physical symptoms of panic attacks. They have the advantage of being fast-acting.

Psychotherapy

The most common therapeutic approach used to treat panic disorder is cognitive behavioral therapy (CBT). This process helps the patient identify a pattern of harmful thoughts and construct strategies and solutions for dealing with them that don’t interfere with functionality.

In some cases, providers may try exposure therapy, in which patients are exposed to the triggers of their panic attacks in a controlled way. This therapy aims to address the fears underlying the panic attacks and allow the patient to return to the activities or situations that they’ve avoided out of fear of an attack.

How Does Panic Disorder Progress?

If left untreated, panic disorder can generate such persistent anxiety and fear that significant life-altering consequences develop, including:

• Major depression
• Other anxiety disorders
• Specific phobias (e.g., fear of driving) or agoraphobia
• Substance abuse
• Relationship dysfunction
• Dysfunction at work or school
• Financial trouble
• Suicide or suicidal thoughts

However, the good news is that with proper diagnosis and treatment, almost 90% of people with panic disorder can lessen the severity of their symptoms.

How Is Panic Disorder Prevented?

Although treatment can help lessen or even eliminate panic disorder symptoms, there is no known definitive cure for the disorder or any way to prevent its onset. However, there are ways to decrease the likelihood that a panic attack will occur, prevent future attacks, or reduce the severity of symptoms when an attack does occur.

• Seek professional help as soon as possible. Getting help from medical and mental health professionals early on can help you head off future attacks and their complications.
• Follow the advice of the professionals. Once you’ve been given a treatment plan, stay on it to prevent future attacks or relapses.
• Learn relaxation techniques. Strategies for relaxation and stress reduction have proven effective at lessening the severity of anxiety disorders, including panic disorder.
• Take care of yourself. Being attentive to your physical health and being physically active has also been shown to help with anxiety.

Panic Disorder Caregiver Tips

Caring for someone with panic disorder or another anxiety disorder can be extremely difficult. The disorder’s symptoms cause stress for the sufferer, but they can cause high levels of stress in caregivers, loved ones, and the people close to the sufferer as well. Caregivers themselves are especially at risk of developing anxiety and depression as a result of their caregiving challenges.

Caregivers for someone with panic disorder should consider these tips to help the sufferer and themselves to deal with the condition:

• First, learn as much as possible about the disorder.
• Seek out appropriate professional treatment for the sufferer.
• Do everything possible to support the sufferer in the pursuit of treatment and help them stay on their treatment plan.
• Learn how to help manage a panic attack when it occurs. Know how to guide the sufferer through relaxation techniques, and know who to call if you need help.
• Find a support group for caregivers.

Many people with panic disorder also suffer from other brain and mental health-related issues, a condition called co-morbidity. Here are a few of the disorders commonly associated with panic disorder:

• Many people with panic disorder also suffer from depression. When the two disorders are comorbid, symptoms of both disorders tend to be worse.
• Many people with panic disorder also have other anxiety disorders such as generalized anxiety disorder or social anxiety disorder.
• Almost half of the people with panic disorder also have a personality disorder such as borderline personality disorder.
• People with post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), agoraphobia, and schizophrenia also often have panic disorder.
• People who experience traumatic brain injuries sometimes develop panic disorder.

Panic Disorder Brain Science

Research into the neurobiology of panic disorder is focused on finding out what happens in the brain when a panic attack occurs, with the ultimate goal of developing more effective diagnostics and treatments. Genetic research, too, is looking for the root causes of panic disorder. With a better understanding of the disorder’s mechanism, doctors will be better able to treat it.

Recent research into the nature of panic disorder includes:

• Researchers at the University of Cincinnati have been looking at a possible link between panic disorder and a particular gene. Previous studies have suggested that panic attacks are sometimes associated with a pH imbalance in the body. The UC researchers are exploring the possibility that an acid-sensing gene (TDAG8) may play a role in creating such an imbalance.
• Imaging studies have found fundamental physical differences in how the brains of people with panic disorder work. These studies have identified changes in the function of some regions of the brain, including the amygdala and the midbrain, when patients are experiencing a panic attack compared to when they are relaxed.

Panic Disorder Research

Title: Comparing Individual Therapies for Veterans With Depression, PTSD, and Panic Disorder

Stage: Recruiting

Principal Investigator:  Daniel F. Gros, PhD MA BS

Ralph H. Johnson VA Medical Center

Charleston, SC

Cognitive behavioral therapy (CBT) is a brief, efficient, and effective treatment for individuals with depressive/anxiety disorders. However, CBT is largely underutilized within the Department of Veterans Affairs due to the cost and burden of training necessary to deliver all related disorder-specific treatments (DSTs). In contrast, transdiagnostic Behavior Therapy (TBT) is specifically designed to address numerous distinct disorders within a single protocol in Veterans with depressive/anxiety disorders, including posttraumatic stress disorder. The proposed research seeks to evaluate the efficacy of TBT by assessing psychiatric symptomatology and related impairment outcomes in Veterans with depressive/anxiety disorders via a randomized controlled trial of TBT and existing DSTs in Veterans with major depressive disorder, posttraumatic stress disorder, and panic disorder. Assessments will be completed at pre-, mid-, and post-treatment, and at 6-month follow-up. Process variables also will be investigated.

Title: Use of CBD Oil in the Treatment of Panic Attack-Related Fear

Stage: Recruiting

Principal Investigator:  Michael J. Telch, PhD

University of Texas

Austin, TX

The proposed research project’s overarching goal is to contribute to developing a novel ultra-brief intervention for anxiety-related psychiatric disorders such as panic disorder and posttraumatic stress disorder (PTSD). Building off innovative work in the fundamental neuroscience of fear memory interference (see Stern et al., 2018 for a review), this experiment will be the first to evaluate whether cannabidiol (CBD) can interfere with the reconsolidation of naturally acquired pathological interoceptive fear memory in humans.

Participants who meet DSM-5 criteria for panic disorder or elevated subthreshold concerns about having additional panic attacks will be randomly assigned to one of three conditions: (1). Memory reactivation + CBD, (2). Memory reactivation+ Placebo, or (3). CBD alone.

NOTE: Due to the COVID-19 Pandemic all study procedures will occur online and over videoconference with study staff. Additionally, CBD or placebo oil will be mailed to the participant’s location.

Title: Measuring Physiology to Determine if Pre-panic Attack Detection is Possible (Pre-Panic Phys)

Stage: Recruiting 

Medical Psychology Center

Beverly, MA

Participants will be asked to wear a physiological monitoring device for 1 week and record when panic events occur. Once the device is returned, the data will be downloaded and analyzed.