Panic disorder: Difference between revisions

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'''For patient information click [[Panic disorder (patient information)|here]]'''
{{SI}}
{{CMG}}; {{AE}} {{Sharma}} {{KS}} {{Y.A}}
 


{{Infobox_Disease
{{SK}} Fit of terror, spasm, anxiety disorder
| Name          = Panic disorder
| Image          =
| Caption        =
| DiseasesDB    = 30913
| ICD10          = F41.0
| ICD9          = {{ICD9|300.01}}, {{ICD9|300.21}}
| OMIM          =
| MedlinePlus    = 000924
| eMedicineSubj  =
| eMedicineTopic =
| MeshID        = }}
{{SI}}
{{CMG}}; {{AE}} {{KS}} {{Y.A}}


==Overview==
==Overview==
*Panic disorder is a [[psychiatric]] condition characterized by recurring [[panic attack]]s in combination with significant behavioral change or at least a month of ongoing worry about the implications or concern about having other attacks.
 
Panic disorder is an [[anxiety]] condition characterized by recurring [[panic attack]]s with significant behavioral change or at least a month of ongoing worry about having another attack. Panic disorder patients have a series of episodic severe [[anxiety]], known as [[panic attacks]].  These attacks typically last 10 minutes, however, they can be of shorter duration. They may vary in intensity and symptoms over a period of time. Symptoms of panic disorder commonly present in the form of [[tachycardia|rapid heart beat]], [[diaphoresis|perspiration]], [[dizziness]], [[dyspnea]], [[tremors]], uncontrollable [[fear]] or feeling of impending doom.  The panic attacks often result in embarrassment and social stigma, ultimately resulting in social isolation. Therefore, most of the individuals with panic disorder also develop [[agoraphobia]]. If not treated, somatic symptoms like [[insomnia]] and/or [[anorexia]] develop, which may eventually result in [[clinical depression]] and [[suicide]]. So, early, efficient, and affordable [[treatment]] options should be encouraged.


==Historical Perspective==
==Historical Perspective==
*It wasn't until 1980 that the DSM-III established a solidified concept of panic disorders. Until this time, panic disorder was being studied separately in both psychology and medicine. <ref name="pmid19698673">{{cite journal| author=Angst J| title=Panic disorder: History and epidemiology. | journal=Eur Psychiatry | year= 1998 | volume= 13 Suppl 2 | issue= | pages= 51s-5s | pmid=19698673 | doi=10.1016/S0924-9338(98)80014-X | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19698673  }} </ref>
*Panic disorder has a long history, dating back to folklores.
*Greek mythology includes one of the examples. The term 'Panic' originated from the Greek god, pan who was responsible for [[anxiety]].<ref name="Nardi2006">{{cite journal|last1=Nardi|first1=Antonio Egidio|title=Some notes on a historical perspective of panic disorder|journal=Jornal Brasileiro de Psiquiatria|volume=55|issue=2|year=2006|pages=154–160|issn=0047-2085|doi=10.1590/S0047-20852006000200010}}</ref>
*In Greek myths, 'pan' was a man with horns and legs of a goat. His mere appearance was so frightening that it developed irrational [[fear]] in people, without any apparent reason. This came to be known as [[panic attacks]] or terrors. <ref name="Nardi2006">{{cite journal|last1=Nardi|first1=Antonio Egidio|title=Some notes on a historical perspective of panic disorder|journal=Jornal Brasileiro de Psiquiatria|volume=55|issue=2|year=2006|pages=154–160|issn=0047-2085|doi=10.1590/S0047-20852006000200010}}</ref>
*Fear of meeting pan once more stopped the travelers from going to the market. In Greek, agora stands for market and this led to the development of a new term [['agoraphobia']]. It stands for the fear of public places or large open spaces.<ref name="Nardi2006">{{cite journal|last1=Nardi|first1=Antonio Egidio|title=Some notes on a historical perspective of panic disorder|journal=Jornal Brasileiro de Psiquiatria|volume=55|issue=2|year=2006|pages=154–160|issn=0047-2085|doi=10.1590/S0047-20852006000200010}}</ref>
*In 1621, Burton described different varieties of [[pathological]] [[anxiety]]. He related the anxiety to [[delirium]], [[depersonalization]], [[hypochondria]], [[hyperventilation]], and [[phobias]].<ref name="Nardi2006">{{cite journal|last1=Nardi|first1=Antonio Egidio|title=Some notes on a historical perspective of panic disorder|journal=Jornal Brasileiro de Psiquiatria|volume=55|issue=2|year=2006|pages=154–160|issn=0047-2085|doi=10.1590/S0047-20852006000200010}}</ref>
*In 1812, Benjamin Rush (father of American psychiatry), described the relation between somatic causes and [[phobias]] in his book. He established an association between [[depression]] and [[hypochondriasis]]. <ref name="Nardi2006">{{cite journal|last1=Nardi|first1=Antonio Egidio|title=Some notes on a historical perspective of panic disorder|journal=Jornal Brasileiro de Psiquiatria|volume=55|issue=2|year=2006|pages=154–160|issn=0047-2085|doi=10.1590/S0047-20852006000200010}}</ref>
*In 1879, Henry Maudsley used the term panic for the first time in [[psychiatry]], and also explained melancholic panic.<ref name="NardiFreire2016">{{cite journal|last1=Nardi|first1=Antonio Egidio|last2=Freire|first2=Rafael Christophe R.|title=The Panic Disorder Concept: A Historical Perspective|year=2016|pages=1–8|doi=10.1007/978-3-319-12538-1_1}}</ref>
*Sigmund Freud, in the year 1925, described [[anxiety]] [[neurosis]]. He separated it from [[neurasthenia]] and further elaborated anxiety neurosis with a particular clinical presentation.<ref name="Nardi2006">{{cite journal|last1=Nardi|first1=Antonio Egidio|title=Some notes on a historical perspective of panic disorder|journal=Jornal Brasileiro de Psiquiatria|volume=55|issue=2|year=2006|pages=154–160|issn=0047-2085|doi=10.1590/S0047-20852006000200010}}</ref>
*In 1964, Klein proposed three types of panic attacks:  situational (related to [[agoraphobia]]), spontaneous, and in response to a stimulus (like height, animals, etc.). <ref name="Nardi2006">{{cite journal|last1=Nardi|first1=Antonio Egidio|title=Some notes on a historical perspective of panic disorder|journal=Jornal Brasileiro de Psiquiatria|volume=55|issue=2|year=2006|pages=154–160|issn=0047-2085|doi=10.1590/S0047-20852006000200010}}</ref>


==Classification==
==Classification==
*There is no established system for the classification of panic disorder
*In 1980, panic disorder was first described in [[DSM-III]], based on Klein's description of [[panic attacks]].<ref name="Nardi2006">{{cite journal|last1=Nardi|first1=Antonio Egidio|title=Some notes on a historical perspective of panic disorder|journal=Jornal Brasileiro de Psiquiatria|volume=55|issue=2|year=2006|pages=154–160|issn=0047-2085|doi=10.1590/S0047-20852006000200010}}</ref> <ref name="pmid19698673">{{cite journal| author=Angst J| title=Panic disorder: History and epidemiology. | journal=Eur Psychiatry | year= 1998 | volume= 13 Suppl 2 | issue=  | pages= 51s-5s | pmid=19698673 | doi=10.1016/S0924-9338(98)80014-X | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19698673  }} </ref>
*In 1987, after consistent work on [[DSM]] for the next seven years, DSM-III-R described [[agoraphobia]] as a consequence of panic disorder. So, [[agoraphobia]] was divided into 'panic disorder with and without [[agoraphobia]]'.<ref name="Nardi2006">{{cite journal|last1=Nardi|first1=Antonio Egidio|title=Some notes on a historical perspective of panic disorder|journal=Jornal Brasileiro de Psiquiatria|volume=55|issue=2|year=2006|pages=154–160|issn=0047-2085|doi=10.1590/S0047-20852006000200010}}</ref>
*In 1992, [[DSM-IV]] described panic attacks related to other conditions. The criteria for panic disorder was not required to be fulfilled here.<ref name="Nardi2006">{{cite journal|last1=Nardi|first1=Antonio Egidio|title=Some notes on a historical perspective of panic disorder|journal=Jornal Brasileiro de Psiquiatria|volume=55|issue=2|year=2006|pages=154–160|issn=0047-2085|doi=10.1590/S0047-20852006000200010}}</ref>
*The criteria for panic disorder remained the same in the revised version of DSM-IV (DSM-IV-TR), published in 2000.<ref name="Nardi2006">{{cite journal|last1=Nardi|first1=Antonio Egidio|title=Some notes on a historical perspective of panic disorder|journal=Jornal Brasileiro de Psiquiatria|volume=55|issue=2|year=2006|pages=154–160|issn=0047-2085|doi=10.1590/S0047-20852006000200010}}</ref>
*[[DSM]]-5 has unlinked panic disorder and [[agoraphobia]]. <ref name="RoestVries2019">{{cite journal|last1=Roest|first1=Annelieke M.|last2=Vries|first2=Ymkje Anna|last3=Lim|first3=Carmen C. W.|last4=Wittchen|first4=Hans‐Ulrich|last5=Stein|first5=Dan J.|last6=Adamowski|first6=Tomasz|last7=Al‐Hamzawi|first7=Ali|last8=Bromet|first8=Evelyn J.|last9=Viana|first9=Maria Carmen|last10=Girolamo|first10=Giovanni|last11=Demyttenaere|first11=Koen|last12=Florescu|first12=Silvia|last13=Gureje|first13=Oye|last14=Haro|first14=Josep Maria|last15=Hu|first15=Chiyi|last16=Karam|first16=Elie G.|last17=Caldas‐de‐Almeida|first17=José Miguel|last18=Kawakami|first18=Norito|last19=Lépine|first19=Jean Pierre|last20=Levinson|first20=Daphna|last21=Medina‐Mora|first21=Maria E.|last22=Navarro‐Mateu|first22=Fernando|last23=O’Neill|first23=Siobhan|last24=Piazza|first24=Marina|last25=Posada‐Villa|first25=José A.|last26=Slade|first26=Tim|last27=Torres|first27=Yolanda|last28=Kessler|first28=Ronald C.|last29=Scott|first29=Kate M.|last30=Jonge|first30=Peter|title=
            A comparison of
            DSM
            ‐5 and
            DSM
            ‐IV agoraphobia in the World Mental Health Surveys
          |journal=Depression and Anxiety|volume=36|issue=6|year=2019|pages=499–510|issn=1091-4269|doi=10.1002/da.22885}}</ref>
*The tenth edition of International Classification of Diseases ([[ICD-10]]) describes [[agoraphobia]] as a distinct condition that may not occur with panic attacks.<ref name="Nardi2006">{{cite journal|last1=Nardi|first1=Antonio Egidio|title=Some notes on a historical perspective of panic disorder|journal=Jornal Brasileiro de Psiquiatria|volume=55|issue=2|year=2006|pages=154–160|issn=0047-2085|doi=10.1590/S0047-20852006000200010}}</ref>


==Pathophysiology==
==Pathophysiology==
*Panic disorder has been found to run in families, and this may mean that [[heredity|inheritance]] plays a strong role in determining who will get it. It has also been found to exist as a co-morbid condition with many hereditary disorders, such as [[bipolar disorder]], and [[alcoholism]]. However, many people who have no [[family]] history of the disorder develop it.
*Multiple factors are associated with the [[pathophysiology]] of panic disorder.
 
*Imbalance of neurobiological, neuroanatomic, and [[neurochemical]] factors lead to the production of this condition.
*Other [[biology|biological]] factors, stressful life events, life transitions, environment, and thinking in a way that exaggerates relatively normal bodily reactions are also believed to play a role in the onset of panic disorder. Often the first attacks are triggered by physical illnesses, major stress, or certain [[medication]]s. People who tend to take on excessive responsibilities may develop a tendency to suffer panic attacks. Post-traumatic stress disorder ([[PTSD]]) patients also show a much higher rate of panic disorder than the general population. The exact causes of panic disorder are unknown at this point.
*Pathogenesis of Panic Disorder is related to the [[amygdala]], the center for [[fear]] processing. MRI studies have further substantiated this finding by showing lesser left and right-sided amygdalar volumes in panic disorder patients as compared to controls. <ref name="KimDager2012">{{cite journal|last1=Kim|first1=Jieun E|last2=Dager|first2=Stephen R|last3=Lyoo|first3=In Kyoon|title=The role of the amygdala in the pathophysiology of panic disorder: evidence from neuroimaging studies|journal=Biology of Mood & Anxiety Disorders|volume=2|issue=1|year=2012|pages=20|issn=2045-5380|doi=10.1186/2045-5380-2-20}}</ref><ref name="MassanaSerra-Grabulosa2003">{{cite journal|last1=Massana|first1=Guillem|last2=Serra-Grabulosa|first2=Josep Maria|last3=Salgado-Pineda|first3=Pilar|last4=Gastó|first4=Cristòbal|last5=Junqué|first5=Carme|last6=Massana|first6=Joan|last7=Mercader|first7=José Maria|last8=Gómez|first8=Beatriz|last9=Tobeña|first9=Adolf|last10=Salamero|first10=Manel|title=Amygdalar atrophy in panic disorder patients detected by volumetric magnetic resonance imaging|journal=NeuroImage|volume=19|issue=1|year=2003|pages=80–90|issn=10538119|doi=10.1016/S1053-8119(03)00036-3}}</ref>
 
*There is dysregulation of the [[prefrontal cortex]] as well as the [[subcortical]] components.<ref name="CoplanLydiard1998">{{cite journal|last1=Coplan|first1=Jeremy D|last2=Lydiard|first2=R.Bruce|title=Brain circuits in panic disorder|journal=Biological Psychiatry|volume=44|issue=12|year=1998|pages=1264–1276|issn=00063223|doi=10.1016/S0006-3223(98)00300-X}}</ref>
*There is some evidence to suggest [[hypoglycemia]], [[hyperthyroidism]], [[mitral valve prolapse]] and [[labyrinthitis]] can aggravate panic disorder.
*The patients with panic disorder have more [[noradrenergic]] neuronal activity than controls. <ref>{{cite journal|title=Neurobiological mechanisms of panic anxiety: biochemical and behavioral correlates of yohimbine-induced panic attacks|journal=American Journal of Psychiatry|volume=144|issue=8|year=1987|pages=1030–1036|issn=0002-953X|doi=10.1176/ajp.144.8.1030}}</ref>
 
*Another neurochemical theory proposes that these patients have deficient [[serotonergic]] inhibition of neurons in the dorsal periaqueductal gray matter of the midbrain and the rostral ventrolateral medulla. <ref name="Graeff2017">{{cite journal|last1=Graeff|first1=Frederico G.|title=Translational approach to the pathophysiology of panic disorder: Focus on serotonin and endogenous opioids|journal=Neuroscience & Biobehavioral Reviews|volume=76|year=2017|pages=48–55|issn=01497634|doi=10.1016/j.neubiorev.2016.10.013}}</ref>
*Studies in [[animal]]s and [[human]]s have focused on pinpointing the specific [[brain]] areas involved in anxiety disorders such as panic disorder. [[Fear]], an emotion that evolved to deal with danger, causes an automatic, rapid protective response that occurs without the need for [[conscious]] [[thought]]. This is termed the [[fight or flight response]]. It has been found that the body's fear response is coordinated by a small but complicated structure deep inside the brain called the [[amygdala]]. [[Eating disorders]] have also been linked to have caused panic attacks in several people. Some mood disorders can cause panic disorder. In addition to [[clinical depression]], [[bipolar disorder]] can cause panic disorder in some people. Due to the nature of the [[fight or flight response]] many cases of panic disorder may be linked with the [[limbic system]] and be initiated by those biological factors that could be biological, reinterpreted emotionally as a threat to survival, such as [[hypoxia]] (lack of oxygen).  If panic disorder is experienced more severely during sleep, it would be recommended to have the sufferer evaluated for conditions such as [[sleep apnea]] or [[hypopnea]]. A sleep-related panic disorder could be most easily distinguished from a [[night terror]] by the ability (usually instantaneous) of the panic disorder sufferer to regain full consciousness, unlike the night terror sufferer.
*The endogenous [[opioids]] buffer the panic attacks in normal subjects and their deficit results in the development of the panic disorder. <ref name="Graeff2017">{{cite journal|last1=Graeff|first1=Frederico G.|title=Translational approach to the pathophysiology of panic disorder: Focus on serotonin and endogenous opioids|journal=Neuroscience & Biobehavioral Reviews|volume=76|year=2017|pages=48–55|issn=01497634|doi=10.1016/j.neubiorev.2016.10.013}}</ref>
 
*Panic disorder patients have also been found to have lower occipital cortex [[GABA]] levels. Other studies suggest dysfunction of GABA(A) receptors in the [[pathophysiology]] of panic disorder. This is further supported by improvement in symptoms by treatment focused on GABA binding site of the GABA(A) and benzodiazepine receptor complex. <ref name="GoddardMason2001">{{cite journal|last1=Goddard|first1=Andrew W.|last2=Mason|first2=Graeme F.|last3=Almai|first3=Ahmad|last4=Rothman|first4=Douglas L.|last5=Behar|first5=Kevin L.|last6=Petroff|first6=Ognen A. C.|last7=Charney|first7=Dennis S.|last8=Krystal|first8=John H.|title=Reductions in Occipital Cortex GABA Levels in Panic Disorder Detected With 1H-Magnetic Resonance Spectroscopy|journal=Archives of General Psychiatry|volume=58|issue=6|year=2001|pages=556|issn=0003-990X|doi=10.1001/archpsyc.58.6.556}}</ref><ref name="RupprechtZwanzger2003">{{cite journal|last1=Rupprecht|first1=R.|last2=Zwanzger|first2=P.|title=Die Bedeutung von GABAA-Rezeptoren f�r Pathophysiologie und Therapie der Panikst�rung|journal=Der Nervenarzt|volume=74|issue=7|year=2003|pages=543–551|issn=0028-2804|doi=10.1007/s00115-002-1433-x}}</ref>
*[[Prepulse inhibition]] has been found to be reduced in patients with panic disorder [http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=543839]. Disorders with PPI deficits are characterized by a loss of the normal ability to suppress or gate irrelevant sensory, motor or cognitive information. This loss of ‘gating’ may be experienced as intrusive thoughts or sensory information. Reduced PPI and gating functions may be a cause of the heightened state of sensory overload that patients suffering from panic attack often experience.  
 
*[[Stimulants]] are a rather common cause for panic attacks. An excess of common stimulants such as [[caffeine]] and [[nicotine]] often can induce panic attacks in less experienced users. Chemicals, including [[carbon monoxide]], in [[tobacco smoke]] can also trigger panic attacks in certain people. Some people's response to small amounts of carbon monoxide is to panic. Not surprisingly, the attacks stop or get much less severe after they quit the cause, such as smoking.
 
*Psychological explanations of panic disorder have also been put forward. Clark (1986) suggests that panic disorder is often caused by "catastrophic misinterpretations", whereby normal bodily sensations, often normal responses to anxiety such as palpitations and sweating, are interpreted as indicating something seriously wrong such as a heart-attack, and this interpretation can be done either consciously or subconsciously. Quite a bit of evidence exists for this theory. For example, activating catastrophic misinterpretations increases anxiety and panic; panic attacks can be reduced as a result of cognitively challenging these misinterpretations; with ambiguous events questionnaires, panic-disorder patients interpret ambiguous sensations more catastrophically than controls. Further, a study by Ehler which provided false heart-rate feedback to participants found that those with panic disorder react with far greater anxiety.


==Differential Diagnosis==
==Differential Diagnosis==
There are some medical and psychiatric conditions with symptoms mimicking panic disorder: <ref name="EdlundMcNamara1991">{{cite journal|last1=Edlund|first1=Matthew J.|last2=McNamara|first2=M.Eileen|last3=Millman|first3=Richard P.|title=Sleep apnea and panic attacks|journal=Comprehensive Psychiatry|volume=32|issue=2|year=1991|pages=130–132|issn=0010440X|doi=10.1016/0010-440X(91)90004-V}}</ref><ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>


*[[Anxiety disorder]] due to another medical condition
*[[Anxiety disorder]] due to other medical condition
:*[[Pheochromocytoma]]
:*[[Hyperthyroidism]]
:*[[Hyperthyroidism]]
:*[[Hyperparathyroidism]]  
:*[[Hyperparathyroidism]]  
:*[[Pheochromocytoma]]
:*Vestibular abnormalities
:*Vestibular dysfunctions
:*[[Seizure disorders]]
:*[[Seizure disorders]]
:*[[Sleep apnea]]
:*Cardiopulmonary conditions
:*Cardiopulmonary conditions
::*[[Arrhythmias]]
::*[[Arrhythmias]]
::*[[Asthma]]
::*[[Supraventricular tachycardia]]
::*[[Supraventricular tachycardia]]
::*[[Asthma]]
::*[[Chronic obstructive pulmonary disease]]
::*[[Chronic obstructive pulmonary disease]]
*Other mental disorders with panic attacks as an associated feature
*Other mental disorders with panic attacks  
:*[[Psychotic disorders]]
:*Other [[anxiety disorders]]
:*Other [[anxiety disorders]]
:*[[Psychotic disorders]]
*Other specified or unspecified [[anxiety disorder]]
*Other specified [[anxiety disorder]] or unspecified [[anxiety disorder]]
*Substance-induced [[anxiety disorder]]
*Substance/medication-induced [[anxiety disorder]]
:*[[Cocaine]]  
:*[[Cocaine]]  
:*[[Amphetamines]]
:*[[Amphetamines]]
:*[[Caffeine]]
:*[[Caffeine]]
:*[[Cannabis]]
:*[[Cannabis]]
:*Withdrawal from central nervous system depressants (e.g., [[alcohol]], [[barbiturate]]s)<ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
*Medication-induced [[anxiety disorder]]
*Withdrawal from CNS depressants like [[alcohol]], [[barbiturate]]s


==Epidemiology and Demographics==
==Epidemiology and Demographics==
===Prevalence===
===Prevalence===
*The 12 month  prevalence of panic disorder is 2,000-3,000 per 100,000 (2%-3%) of the overall population. 2.7-7.1% of the general population suffers from a lifetime prevalence of panic disorder, meaning repeated panic attacks. <ref name="pmid19698673">{{cite journal| author=Angst J| title=Panic disorder: History and epidemiology. | journal=Eur Psychiatry | year= 1998 | volume= 13 Suppl 2 | issue=  | pages= 51s-5s | pmid=19698673 | doi=10.1016/S0924-9338(98)80014-X | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19698673  }} </ref> <ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>  
*The prevalence of the panic disorder is 2,000-3,000 / 100,000 (2%-3%) of the overall [[population]].  
*2.7-7.1% of the general [[population]] suffers from a lifetime [[prevalence]] of panic disorder. <ref name="pmid19698673">{{cite journal| author=Angst J| title=Panic disorder: History and epidemiology. | journal=Eur Psychiatry | year= 1998 | volume= 13 Suppl 2 | issue=  | pages= 51s-5s | pmid=19698673 | doi=10.1016/S0924-9338(98)80014-X | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19698673  }} </ref> <ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>


===Gender===
===Gender===
*Women are twice as likely as men to develop panic disorder. <ref>{{cite web| url=http://www.nimh.nih.gov/publicat/panicfacts.cfm| title= Facts about Panic Disorder| publisher=National Institute of Mental Health|
*Women are twice as likely as men to develop panic disorder. <ref>{{cite web| url=http://www.nimh.nih.gov/publicat/panicfacts.cfm| title= Facts about Panic Disorder| publisher=National Institute of Mental Health|
  accessdate=2006-09-30}}</ref>
  accessdate=2006-09-30}}</ref>
*For both men and women, panic disorder has similar age of onset. Preceding premorbidity was found to be different for men and women.<ref name="BarzegaMaina2001">{{cite journal|last1=Barzega|first1=Giulio|last2=Maina|first2=Giuseppe|last3=Venturello|first3=Sara|last4=Bogetto|first4=Filippo|title=Gender-related differences in the onset of panic disorder|journal=Acta Psychiatrica Scandinavica|volume=103|issue=3|year=2001|pages=189–195|issn=0001690X|doi=10.1034/j.1600-0447.2001.00194.x}}</ref>
*Men had higher rates of body dysmorphic disorder, cyclothymia, and [[depersonalization]] preceding panic disorder. Whereas, women had higher rates of [[bulimia nervosa]]. Life stressors played a significant precipitating factor for women. <ref name="BarzegaMaina2001">{{cite journal|last1=Barzega|first1=Giulio|last2=Maina|first2=Giuseppe|last3=Venturello|first3=Sara|last4=Bogetto|first4=Filippo|title=Gender-related differences in the onset of panic disorder|journal=Acta Psychiatrica Scandinavica|volume=103|issue=3|year=2001|pages=189–195|issn=0001690X|doi=10.1034/j.1600-0447.2001.00194.x}}</ref>


===Age===
===Age===
*Panic disorder typically strikes in early [[adult]]hood; roughly half of all people who have panic disorder develop the condition before age 24, especially if the person has been subjected to a traumatic experience. However, some sources say that the majority of young people affected for the first time are between the ages of 25 and 30.
*Anticipation is characterized by the decrease in [[age at onset]] and/or the increase in severity of a disorder in successive generations. It helps in exploring the [[genetic]] basis of some diseases.
*Anticipation is responsible for the [[familial]] aggregation of panic disorder. <ref name="BattagliaBertella1998">{{cite journal|last1=Battaglia|first1=Marco|last2=Bertella|first2=Silvana|last3=Bajo|first3=Sonia|last4=Binaghi|first4=Flora|last5=Bellodi|first5=Laura|title=Anticipation of Age at Onset in Panic Disorder|journal=American Journal of Psychiatry|volume=155|issue=5|year=1998|pages=590–595|issn=0002-953X|doi=10.1176/ajp.155.5.590}}</ref>
*There is an increased risk of disease in the relatives of panic disorder patients with age of onset 20 years or less. The age of onset is useful in determining the familial subtypes. <ref name="Goldstein1997">{{cite journal|last1=Goldstein|first1=Rise B.|title=Familial Aggregation and Phenomenology of 'Early'-Onset (at or Before Age 20 Years)|journal=Archives of General Psychiatry|volume=54|issue=3|year=1997|pages=271|issn=0003-990X|doi=10.1001/archpsyc.1997.01830150097014}}</ref>
 
===Race===
*Various studies presented with mixed results.
*A study comparing the White, African American, Asian, and Latino groups found that the Whites had higher rates of panic disorder, as compared to the African American, Latino, and Asian groups.<ref name="AsnaaniGutner2009">{{cite journal|last1=Asnaani|first1=Anu|last2=Gutner|first2=Cassidy A.|last3=Hinton|first3=Devon E.|last4=Hofmann|first4=Stefan G.|title=Panic Disorder, Panic Attacks and Panic Attack Symptoms across Race-Ethnic Groups: Results of the Collaborative Psychiatric Epidemiology Studies|journal=CNS Neuroscience & Therapeutics|volume=15|issue=3|year=2009|pages=249–254|issn=17555930|doi=10.1111/j.1755-5949.2009.00092.x}}</ref>


==Risk Factors==
==Risk Factors==
Several factors can increase the chances of Panic Disorder: <ref name="Roy-ByrneCraske2006">{{cite journal|last1=Roy-Byrne|first1=Peter P|last2=Craske|first2=Michelle G|last3=Stein|first3=Murray B|title=Panic disorder|journal=The Lancet|volume=368|issue=9540|year=2006|pages=1023–1032|issn=01406736|doi=10.1016/S0140-6736(06)69418-X}}</ref><ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>


*[[Asthma]]
*[[Asthma]]
*Anxiety sensitivity
*Childhood sexual and physical [[abuse]]
*Childhood experiences of sexual and physical abuse
*[[Genetic predisposition]]
*Genetic predisposition
*History of "fearful spells"
*History of "fearful spells"
*Identifiable stressors
*Identifiable stressors
:*Interpersonal stressors
:*Interpersonal stressors
:*Stressors related to physical well-being
:*Stressors related to physical well-being
::*Negative experiences with illicit or prescription drugs
::*Negative experiences with illicit or [[prescription drug]]s
::*Disease
::*Disease
::*Death in the family
::*Death in the family
*Negative affectivity (neuroticism)  
*Negative affect (neuroticism)  
*Offspring of parents with anxiety, depressive,and [[bipolar disorders]]
*Offsprings of parents with [[anxiety]], [[depression]], or [[bipolar disorder]]s
*[[Separation anxiety in childhood]]
*Separation anxiety in childhood
*Smoking<ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
*Smoking


==Natural History, Complications, and Prognosis==
==Natural History, Complications, and Prognosis==
*Anxiousness and overadaptation in people with panic disorder begins in childhood. This can be the result of traumatic life events or distressing family conditions.<ref name="pmid1776498">{{cite journal| author=Angst J, Vollrath M| title=The natural history of anxiety disorders. | journal=Acta Psychiatr Scand | year= 1991 | volume= 84 | issue= 5 | pages= 446-52 | pmid=1776498 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1776498  }} </ref>
*Anxiousness in people with panic disorder begins in [[childhood]] due to traumatic life events or distressing family conditions.<ref name="pmid1776498">{{cite journal| author=Angst J, Vollrath M| title=The natural history of anxiety disorders. | journal=Acta Psychiatr Scand | year= 1991 | volume= 84 | issue= 5 | pages= 446-52 | pmid=1776498 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1776498  }} </ref>
*Family history and [[genetics]] play a very important role in the development of panic disorder.
*Poor [[prognostic]] factors are:<ref>{{cite journal|doi=10.1007/BF00452785}}</ref><ref name="pmid9402913">{{cite journal| author=Liebowitz MR| title=Panic disorder as a chronic illness. | journal=J Clin Psychiatry | year= 1997 | volume= 58 Suppl 13 | issue=  | pages= 5-8 | pmid=9402913 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9402913  }} </ref><ref name="ErsoySelek2009">{{cite journal|last1=Ersoy|first1=Mehmet Akif|last2=Selek|first2=Salih|last3=Celik|first3=Hakim|last4=Erel|first4=Ozcan|last5=Kaya|first5=Mehmet Cemal|last6=Savas|first6=Haluk A.|last7=Herken|first7=Hasan|title=Role of Oxidative and Antioxidative Parameters in Etiopathogenesis and Prognosis of Panic Disorder|journal=International Journal of Neuroscience|volume=118|issue=7|year=2009|pages=1025–1037|issn=0020-7454|doi=10.1080/00207450701769026}}</ref><ref name="KeijsersHoogduin1994">{{cite journal|last1=Keijsers|first1=Ger P.J.|last2=Hoogduin|first2=Cees A.L.|last3=Schaap|first3=Cas P.D.R.|title=Prognostic factors in the behavioral treatment of panic disorder with and without agoraphobia|journal=Behavior Therapy|volume=25|issue=4|year=1994|pages=689–708|issn=00057894|doi=10.1016/S0005-7894(05)80204-7}}</ref><ref name="CoryellNoyes1991">{{cite journal|last1=Coryell|first1=William|last2=Noyes|first2=Russell|last3=Reich|first3=James|title=The prognostic significance of HPA-axis disturbance in panic disorder: A three-year follow-up|journal=Biological Psychiatry|volume=29|issue=2|year=1991|pages=96–102|issn=00063223|doi=10.1016/0006-3223(91)90038-N}}</ref>
:*Female gender
:*Comorbid agoraphobia
:*Comorbid [[depression]]
:*Comorbid [[personality disorder]]
:*Higher oxidative stress index and higher ceruloplasmin level
:*Catastrophic agoraphobic cognitions
:*Panic disorder patients with non-suppression on Dexamethasone Suppression Test (DST)


==Diagnostic Criteria==
==Diagnostic Criteria==


===DSM-V Diagnostic Criteria for Panic Disorder<ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>===
===DSM-5 Diagnostic Criteria for Panic Disorder<ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>===
{{cquote|
 


*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;
*A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense [[fear]] or discomfort that reaches a peak within minutes, and associated with at least four of these symptoms:


<SMALL>''Note:The abrupt surge can occur from a calm state or an anxious state.''</SMALL>
<SMALL>'' Note: The abrupt surge can occur from a calm state or an [[anxious]] state.''</SMALL>


:*1. [[Palpitations]], pounding heart, or accelerated heart rate.
:*1. [[Palpitations]]
:*2. Sweating.
:*2. Sweating
:*3. Trembling or shaking.
:*3. Trembling  
:*4. Sensations of shortness of breath or smothering.
:*4. Shortness of breath  
:*5. Feelings of choking.
:*5. Feeling of choking
:*6. [[Chest pain]] or discomfort.
:*6. [[Chest pain]] or discomfort
:*7. [[Nausea]] or [[abdominal distress]].
:*7. [[Nausea]] or [[abdominal distress]]
:*8. [[Feeling dizzy]], unsteady, light-headed, or faint.
:*8. [[Feeling dizzy]], or unsteady
:*9. [[Chills]] or heat sensations.
:*9. [[Chills]] or sensation of heat
:*10. [[Paresthesia]]s (numbness or tingling sensations).
:*10. [[Paresthesia]]s (numbness or tingling sensations)
:*11. Derealization (feelings of unreality) or depersonalization (being detached from oneself).
:*11. Derealization (feelings of unreality) or depersonalization (being detached from oneself)
:*12. Fear of losing control or “going crazy.”
:*12. Fear of losing control  
:*13. Fear of dying.
:*13. Fear of dying
<SMALL>''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.''</SMALL>
<SMALL>''Note: Culture-specific symptoms (e.g., [[tinnitus]], neck soreness, [[headache]], uncontrollable screaming or crying) may occur. Such symptoms should not be included as one of the four required symptoms.''</SMALL>


'''''AND'''''
'''''AND'''''


*B. At least one of the attacks has been followed by 1 month (or more) of one or both of the following:
*B. At least one of the attacks has been followed by a minimum of 1 month of the following:


:*1. Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, “going crazy”).
:*1. Persistent worries about having another panic attack or the consequences (like losing control).
:*2. 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).
:*2. A major maladaptive behavioral change in relation to the attacks (behaviors to avoid having panic attacks).


'''''AND'''''
'''''AND'''''


*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).
*C. The disturbance is not due to the effects of a substance or another medical condition.  


'''''AND'''''
'''''AND'''''


*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 [[post traumatic stress disorder]]: or in response to separation from attachment figures, as in [[separation anxiety disorder]]).
*D. The disturbance is not better explained by another mental disorder or due to separation from attachment figures.
}}
 
==History and Symptoms==
*Panic disorder sufferers usually have a series of intense episodes of extreme [[anxiety]], known as [[panic attacks]].  These attacks typically last 10 minutes,however, they can be short-lived at around 1-5 minutes as well. Attacks can wax and wane for a period of hours- one panic attack rolling into another. They may vary in intensity and specific symptoms of panic over the duration (i.e. [[Tachycardia|rapid heartbeat]], [[Diaphoresis|perspiration]], [[dizziness]], [[dyspnea]], [[Tremor|trembling]], psychological experience of uncontrollable [[fear]], [[clinical depression]], etc.).  Some individuals deal with these events on a regular basis&mdash;sometimes daily or weekly. The outward symptoms of a panic attack often cause negative social experiences (i.e. embarrassment, social stigma, social isolation, etc.). As a result, as many as 36% of all individuals with panic disorder also have [[agoraphobia]]. If not treated, both [[insomnia]] and/or [[anorexia]] can occur.


==Laboratory Findings==
===Diagnosis in practice===
*There are no diagnostic laboratory findings associated with panic disorder.
Brief, screening and diagnostic surveys have been reviewed by the [[United States Preventive Services Task Force]] (USPSTF)<ref>O’Connor E, Henninger M, Perdue LA, Coppola EL, Thomas R, Gaynes BN. Screening for Depression, Anxiety, and Suicide Risk in Adults: A Systematic Evidence Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 223. AHRQ Publication No. 22-05295-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2022</ref>.


==Other Imaging Studies==
The draft [[USPSTF]] guideline recommends screening<ref>https://www.uspreventiveservicestaskforce.org/uspstf/draft-recommendation/anxiety-adults-screening</ref>.
*Recently, structural neuroimaging methods can help to identify potential brain morphological alterations that could possibly relate to the clinical expression of panic disorder.<ref name="pmid23793273">{{cite journal| author=Del Casale A, Serata D, Rapinesi C, Kotzalidis GD, Angeletti G, Tatarelli R et al.| title=Structural neuroimaging in patients with panic disorder: findings and limitations of recent studies. | journal=Psychiatr Danub | year= 2013 | volume= 25 | issue= 2 | pages= 108-14 | pmid=23793273 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23793273  }} </ref>


==Other Diagnostic Studies==
1. The Brief Panic Disorder Severity Scale–Self-Report (Brief PDSS-SR) can also be used for diagnosis<ref name="pmid31349178">{{cite journal| author=Forsell E, Kraepelien M, Blom K, Isacsson N, Jernelöv S, Svanborg C | display-authors=etal| title=Development of a very brief scale for detecting and measuring panic disorder using two items from the Panic Disorder Severity Scale-Self Report. | journal=J Affect Disord | year= 2019 | volume= 257 | issue=  | pages= 615-622 | pmid=31349178 | doi=10.1016/j.jad.2019.07.057 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31349178  }} </ref>:
*There are no other diagnostic studies associated with panic disorder.
* Two items (questions 2 and 4 from the Panic Disorder Severity Scale - Self Report (PDSS-SR)
** 2. Distress during panic: "If you had any panic attacks during the past week, how distressing (uncomfortable, frightening) were they while they were happening? (If you had more than one, give an average rating. If you didn't have any panic attacks but did have limited symptom attacks, answer for the limited symptom attacks.)
** 4. Avoidance, agoraphobic: "During the past week were there any places or situations (e.g., public transportation, movie theaters, crowds, bridges, tunnels, shopping malls, being alone) you avoided, or felt afraid of (uncomfortable in, wanted to avoid or leave), because of fear of having a panic attack? Are there any other situations that you would have avoided or been afraid of if they had come up during the week, for the same reason? If yes to either question, please rate your level of fear and avoidance this past week."
* Sum of 3 or more points<ref name="pmid31349178"/>:
** Sensitivity of 0.85
** Specificity of 0.66
** [[Diagnostic test | Gain in certainty]] (Sensitivy + specifity)<ref name="pmid4014166">{{cite journal| author=Connell FA, Koepsell TD| title=Measures of gain in certainty from a diagnostic test. | journal=Am J Epidemiol | year= 1985 | volume= 121 | issue= 5 | pages= 744-53 | pmid=4014166 | doi=10.1093/aje/121.5.744 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4014166  }} </ref> 1.5 (0.85 + 0.66)


==Treatment==
2. Panic Disorder Severity Scale–Self-Report (PDSS-SR)<ref name="pmid31349178">{{cite journal| author=Forsell E, Kraepelien M, Blom K, Isacsson N, Jernelöv S, Svanborg C | display-authors=etal| title=Development of a very brief scale for detecting and measuring panic disorder using two items from the Panic Disorder Severity Scale-Self Report. | journal=J Affect Disord | year= 2019 | volume= 257 | issue=  | pages= 615-622 | pmid=31349178 | doi=10.1016/j.jad.2019.07.057 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31349178  }} </ref>:
Panic Disorder is real and potentially disabling, but it can be controlled and successfully treated. Because of the disturbing symptoms that accompany panic disorder, it may be mistaken for a life-threatening physical [[illness]]. This misconception often aggravates or triggers future attacks. People frequently go to hospital [[emergency room]]s when they are having panic attacks, and extensive medical tests may be performed to rule out these other conditions, thus creating further anxiety. Medical tests which do not identify an underlying physical cause are not uncommon. In the case of severe reactive hypoglycemia, a sudden drop in blood sugar is often overlooked in a healthy person, while tests are designed to reveal the blood-sugar profile of a diabetic rather than an individual with this specific disorder. Pursuing healthy nutritional therapy in the case of any psychiatric illness is essential.   
* Cutoff cutoff ≥9:
** Sensitivity of 67% to 83%
** Specificity of 64% to 96%
** [[Diagnostic test | Gain in certainty]] (Sensitivy + specifity)<ref name="pmid4014166">{{cite journal| author=Connell FA, Koepsell TD| title=Measures of gain in certainty from a diagnostic test. | journal=Am J Epidemiol | year= 1985 | volume= 121 | issue= 5 | pages= 744-53 | pmid=4014166 | doi=10.1093/aje/121.5.744 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4014166 }} </ref> 1.5 (0.75 + 0.79)


Some individuals with panic disorder have turned to [[Medication]]s and a type of [[psychotherapy]] known as [[cognitive-behavioral therapy]]. The [[mental health professional]]s that typically can assist an individual in treatment of panic disorder are [[psychiatrist]]s, [[psychologist]]s, [[Mental Health Counselor|mental health counselors]], and [[social worker]]s. To pursue a medical treatment for panic disorder, one should visit a medical doctor, typically a psychiatrist. Psychotherapy is typically provided by a clinical or counseling psychologist, a [[Licensed Professional Counselor]] (LPC), or a Licensed Clinical Social Worker ([[LCSW]])In remote areas, or when a psychiatrist is unavailable, a [[General practitioner|general practice physician]] ("family doctor") may be competent to manage the [[pharmacological]] ("medications") treatment in coordination with a [[psychologist]] or LCSWA [[psychiatrist]] is, by training, better prepared than a general practice physician in the pharmacological treatment and should be sought out if available.
3. PHQ-PD<ref name="pmid10568646">{{cite journal| author=Spitzer RL, Kroenke K, Williams JB| title=Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. | journal=JAMA | year= 1999 | volume= 282 | issue= 18 | pages= 1737-44 | pmid=10568646 | doi=10.1001/jama.282.18.1737 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10568646 }} </ref>:
* Criteria: questions #3a-d are all YES and 4 or more of #4a-k are YES:
** Sensitivity of 81%
** Specificity of 99%
** [[Diagnostic test | Gain in certainty]] (Sensitivy + specifity)<ref name="pmid4014166">{{cite journal| author=Connell FA, Koepsell TD| title=Measures of gain in certainty from a diagnostic test. | journal=Am J Epidemiol | year= 1985 | volume= 121 | issue= 5 | pages= 744-53 | pmid=4014166 | doi=10.1093/aje/121.5.744 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4014166 }} </ref> 1.8


Medications can be used to break the psychological connection between a specific [[phobia]] and panic attacks. Medications can include:
4. GAD-7
* [[antidepressants]] ([[selective serotonin reuptake inhibitor|SSRI]]s, [[Monoamine oxidase inhibitors|MAOI]]s, etc.) : these are taken regularly every day, and build a resistance to the occurrence of the symptoms.  Although these medications are described as "antidepressants," nearly all of them have anti-panic properties as well - many panic sufferers do not have classical symptoms of depression, and may be misled by the name "antidepressant" into believing these drugs are not targeted to their symptoms, when they are often the most effective treatment in combination with psychotherapy.
* Sensitivity: 61%-89%
* [[anti-anxiety drugs]] ([[benzodiazepines]]): these drugs are taken during or at the onset of panic attacks or before challenging/anxiety provoking situations. Some sufferers also take them daily to prevent panic attacks from occurring. These drugs may be habit-forming if not used according to a physician's directionsThey are often most effective at the beginning of treatment when the resistance properties of the antidepressants have not yet built up, and are generally utilized less and less as other parts of the treatment (antidepressants, psychotherapy) become more effective.
* Specificity: 82%-88%
** [[Diagnostic test | Gain in certainty]] (Sensitivy + specifity)<ref name="pmid4014166">{{cite journal| author=Connell FA, Koepsell TD| title=Measures of gain in certainty from a diagnostic test. | journal=Am J Epidemiol | year= 1985 | volume= 121 | issue= 5 | pages= 744-53 | pmid=4014166 | doi=10.1093/aje/121.5.744 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4014166 }} </ref> 1.6 (0.75 + 0.85)


Exposure to the phobia trigger multiple times without a resulting panic attack (due to medication) can often break the phobia-panic pattern, allowing people to function around their phobia without the help of medications. However, minor phobias that develop as a result of the panic attack can often be eliminated without medication through monitored [[cognitive-behavioral therapy]] or simply by exposure.
==Treatment==
 
Usually, a combination of psychotherapy and medications produces good results. Some improvement may be noticed in a fairly short period of time -- about 6 to 8 weeks. Often, it may take longer to find the right pair of medications and mental health professional. Thus appropriate treatment by an experienced professional can prevent panic attacks or at least substantially reduce their severity and frequency -- bringing significant relief to 70 to 90 percent of people with panic disorder. <ref>{{cite web| url=http://www.pueblo.gsa.gov/cic_text/health/panic/panfly.htm| title=Panic Disorder| publisher=National Institute of Mental Health| accessdate=2006-05-12}}</ref> Relapses may occur, but they can often be effectively treated just like the initial episode.
 
In addition, people with panic disorder may need treatment for other emotional problems. [[Clinical depression]] has often been associated with panic disorder, as have [[alcoholism]] and [[drug addiction]].  Research has also suggested that [[Suicide#Attempted suicide|suicide attempts]] are more frequent in people with panic disorder, although this research remains controversial.
 
Experimental treatment for panic disorder has included nutritional consultation and the  use of substances such as inositol, amino acid gamma-aminobutyric acid (GABA), glycine, glutamine, and the calming amino acid L-theanine. Treatment with GABA is both questionable and controversial, as orally ingested GABA cannot cross the blood-brain barrier.[[Orthomolecular therapy]] useful in the treatment of depression or which enhances the healthy functioning of the brain may have a role in the treatment of this condition.
 
About 30% of people with panic disorder use [[alcoholic beverage|alcohol]] and 17% abuse psychoactive drugs.<ref>{{cite web| url=http://www.nmha.org/go/panic-disorder| title=Panic Disorder| publisher=Mental Health America| accessdate=2007-07-02}}</ref>  This is in comparison with 61% (alcohol)[http://www.cdc.gov/nchs/fastats/alcohol.htm] and 7.9% (other psychoactive drugs) [http://www.cdc.gov/nchs/fastats/druguse.htm] of the general population who use alcohol and psychoactive drugs, respectively.  It often varies between individual cases whether any observed drug use worsens the condition, or is initiated by the sufferer to alleviate the condition ("[[self medication]]").  Most stimulant drugs (caffeine, nicotine, cocaine) would be expected to worsen the condition, since they directly increase the symptoms of panic, such as heart rate.  The medically established psychoactive properties of [[Health issues and the effects of cannabis|marijuana]] present a special case - at low doses there may be some anti-anxiety psychological effects comparable to those of [[benzodiazepines]], whereas at some undefined threshold (as dose is increased), marijuana has been shown to produce extreme anxiety on its own, with an intensity potentially comparable to that of the panic disorder symptoms themselves.[http://www.yale.edu/opa/newsr/04-06-14-01.all.html] However, generally only new marijuana users experience anxiety because they are not used to their heart rate temporarily being increased.[http://homepages.poptel.org.uk/DrDrew/health.html#mind]
 
As with many disorders, having a support structure of family and friends who understand the condition can help increase the rate of recovery. During an attack, it is not uncommon for the sufferer to develop irrational, immediate fear, which can often be dispelled by a supporter who is familiar with the condition. For more serious or active treatment, there are support groups for anxiety sufferers which can help people understand and deal with the disorder.
 
Other forms of treatment include [[Personal journal|journalling]], in which a patient records their day-to-day activities and emotions in a log to find and deal with their personal stresses. Breathing exercises, such as [[diaphragmatic breathing]], can also be found helpful. In some cases, a therapist may use a procedure called [[interoceptive exposure]], in which the symptoms of a panic attack are induced in order to promote coping skills and show the patient that no harm can come from a panic attack. Stress-relieving activities such as [[Tai chi chuan|tai-chi]], [[yoga]], and [[physical exercise]] can also help ameliorate the causes of panic disorder. Many physicians will recommend [[stress management]], [[time management]], and emotion-balancing classes and seminars to help patients avoid anxiety in the future. Research has also shown that the herbal supplement [[5-HTP]] can be used to treat panic disorders by its ability to boost serotonin levels. This works by providing the body with the raw material to make serotonin, as opposed to SSRIs which work by recycling serotonin.
 
==Medical Therapy==
*Medication can be given to help treat the anxiety-like symptoms of panic disorder.


==Psychotherapy==
*Panic Disorder is a potentially disabling condition but can be successfully treated.
*One particularly helpful and effective form of [[Cognitive Behavioral Therapy]] (CBT) is Interoceptive Desensitization. Techniques used may include those based upon the concept that intentional exposure to the symptoms will help decrease the sufferer's fear of panic attacks. In a study by Barlow & Craske (1989), 87% of the individuals that participated in the two of four treatments that involved Interoceptive Desensitization were free of panic at the end of treatment and these results were maintained at a 2-year follow up.  In controlled studies of Interoceptive Desensitization treatments compared to other treatments, those treatments that included Interoceptive Desensitization were found to be significantly superior to other treatments such as muscle relaxation alone, or education or insight-oriented treatments. Indeed, Interoceptive Desensitization often leads to a dramatic reduction in the frequency and intensity of panic attacks and as such should be implemented immediately under the guidance of a [[mental health professional]]. '''It is important the patient is given medical clearance and permission from a [[medical doctor]] before attempting these exercises.'''
*Due to the disturbing symptoms that accompany the panic disorder, it can be mistaken for a life-threatening physical [[illness]].  
*Thorough investigation to rule out the suspected medical condition and early initiation of [[treatment]] should be the ultimate goal of managing the panic disorder.
*Panic disorder can be treated by [[medication]]s, [[psychotherapy]], or both.
*A skilled treating team of [[psychiatrist]]s, [[psychologist]]s, and [[social worker]]s is required for this purpose.


*Symptom Inductions generally occur for '''one minute''' and may include:
===Medications===
*[[Antidepressants]] ([[selective serotonin reuptake inhibitor|SSRI]]s, [[Monoamine oxidase inhibitors|MAOI]]s, Tricyclic Antidepressants (TCAs), etc.)
:*SSRIs such as paroxetine, escitalopram, and citalopram, are used for maintenance therapy. <ref name="StahlGergel2003">{{cite journal|last1=Stahl|first1=Stephen M.|last2=Gergel|first2=Ivan|last3=Li|first3=Dayong|title=Escitalopram in the Treatment of Panic Disorder|journal=The Journal of Clinical Psychiatry|volume=64|issue=11|year=2003|pages=1322–1327|issn=0160-6689|doi=10.4088/JCP.v64n1107}}</ref><ref name="BallengerWheadon1998">{{cite journal|last1=Ballenger|first1=James C.|last2=Wheadon|first2=David E.|last3=Steiner|first3=Martin|last4=Bushnell|first4=William|last5=Gergel|first5=Ivan P.|title=Double-Blind, Fixed-Dose, Placebo-Controlled Study of Paroxetine in the Treatment of Panic Disorder|journal=American Journal of Psychiatry|volume=155|issue=1|year=1998|pages=36–42|issn=0002-953X|doi=10.1176/ajp.155.1.36}}</ref>
:*MAOIs are usually avoided because of the life-threatening side effects such as [[serotonin syndrome]], hypertensive crisis, and other drug interactions.
:*TCAs are associated with [[anticholinergic]] side effects, so avoided in the elderly.
:*Both SSRIs and TCAs are effective for the treatment but SSRIs are preferred because of a better tolerability profile.<ref name="BakkerVan Balkom2002">{{cite journal|last1=Bakker|first1=A.|last2=Van Balkom|first2=A. J. L. M.|last3=Spinhoven|first3=P.|title=SSRIs vs. TCAs in the treatment of panic disorder: a meta-analysis|journal=Acta Psychiatrica Scandinavica|volume=106|issue=3|year=2002|pages=163–167|issn=0001690X|doi=10.1034/j.1600-0447.2002.02255.x}}</ref>
*[[Anti-anxiety drugs]] ([[benzodiazepines]] such as Alprazolam, Clonazepam )
:*These are used for a short duration to control the acute phase of illness or given until the [[SSRIs]] have achieved therapeutic action.
:*Long-term use is not advisable because of the high chances of developing dependence and drug-seeking behavior.


*'''Intentional Hyperventilation'''- Creates [[lightheadedness]], [[derealization]], blurred vision, [[dizziness]]
===Psychotherapy===
*'''Spinning in a chair'''- Creates [[dizziness]], [[disorientation]]
*There are multiple treatment options available such as exposure to somatic cues, [[cognitive behavior therapy]] (CBT), and relaxation therapy for panic disorder. When combined, these management options provide the best results.
*'''Straw breathing'''- Creates [[dyspnea]], airway constriction
*Exposure to somatic cues and [[CBT]], when combined result in nearly 85% response rate. <ref name="BarlowCraske1989">{{cite journal|last1=Barlow|first1=David H.|last2=Craske|first2=Michelle G.|last3=Cerny|first3=Jerome A.|last4=Klosko|first4=Janet S.|title=Behavioral treatment of panic disorder|journal=Behavior Therapy|volume=20|issue=2|year=1989|pages=261–282|issn=00057894|doi=10.1016/S0005-7894(89)80073-5}}</ref>
*'''Breath holding'''- Creates sensation of being out of [[breath]]
*Relaxation techniques produce greater reduction in the associated [[anxiety]] but are related to higher drop-out rates. <ref name="BarlowCraske1989">{{cite journal|last1=Barlow|first1=David H.|last2=Craske|first2=Michelle G.|last3=Cerny|first3=Jerome A.|last4=Klosko|first4=Janet S.|title=Behavioral treatment of panic disorder|journal=Behavior Therapy|volume=20|issue=2|year=1989|pages=261–282|issn=00057894|doi=10.1016/S0005-7894(89)80073-5}}</ref>
*'''Running in place'''- Creates increased [[heart rate]], [[Respiratory system|respiration]] [[perspiration]]
*CBT can also be administered in the form of group therapy. It is found to be equally effective as [[pharmacotherapy]] in some studies.<ref name="TelchLucas1993">{{cite journal|last1=Telch|first1=Michael J.|last2=Lucas|first2=John A.|last3=Schmidt|first3=Norman B.|last4=Hanna|first4=Henry H.|last5=Jaimez|first5=T.LaNae|last6=Lucas|first6=Richard A.|title=Group cognitive-behavioral treatment of panic disorder|journal=Behaviour Research and Therapy|volume=31|issue=3|year=1993|pages=279–287|issn=00057967|doi=10.1016/0005-7967(93)90026-Q}}</ref>
*'''Body Tensing'''- Creates feelings of being tense and vigilante
*CBT comprises of: <ref name="TelchLucas1993">{{cite journal|last1=Telch|first1=Michael J.|last2=Lucas|first2=John A.|last3=Schmidt|first3=Norman B.|last4=Hanna|first4=Henry H.|last5=Jaimez|first5=T.LaNae|last6=Lucas|first6=Richard A.|title=Group cognitive-behavioral treatment of panic disorder|journal=Behaviour Research and Therapy|volume=31|issue=3|year=1993|pages=279–287|issn=00057967|doi=10.1016/0005-7967(93)90026-Q}}</ref>
:*Education and corrective information
:*Cognitive therapy
:*Training in diaphragmatic breathing
:*Interoceptive exposure


*The key to the induction is that the exercises should mimic the most frightening symptoms of a panic attack. Symptom Inductions should be repeated 3-5 times per day until the patient has little to no anxiety in relation to the symptoms that were induced. Often it will take a period of weeks for the afflicted to feel no anxiety in relation to the induced symptoms. With repeated trials, a person learns through experience that these internal sensations do not need to be feared – the individual becomes less sensitized or desensitized to the internal sensation. After repeated trials, when nothing catastrophic happens, the brain learns ([[Hippocampus]] & [[Amygdala]]) to not fear the sensations, and the [[sympathetic nervous system]] activation fades.
===Other treatment modalities===
*Regular aerobic exercise alone has been associated with clinical improvement in patients with panic disorder but is lesser effective than [[pharmacotherapy]]. <ref name="BroocksBandelow1998">{{cite journal|last1=Broocks|first1=Andreas|last2=Bandelow|first2=Borwin|last3=Pekrun|first3=Gunda|last4=George|first4=Annette|last5=Meyer|first5=Tim|last6=Bartmann|first6=Uwe|last7=Hillmer-Vogel|first7=Ursula|last8=Rüther|first8=Eckart|title=Comparison of Aerobic Exercise, Clomipramine, and Placebo in the Treatment of Panic Disorder|journal=American Journal of Psychiatry|volume=155|issue=5|year=1998|pages=603–609|issn=0002-953X|doi=10.1176/ajp.155.5.603}}</ref>
*When properly used, Internet-based self-help programs with minimal therapist contact can be equally efficacious as traditional individual [[CBT]]. <ref name="CarlbringNilsson-Ihrfelt2005">{{cite journal|last1=Carlbring|first1=Per|last2=Nilsson-Ihrfelt|first2=Elisabeth|last3=Waara|first3=Johan|last4=Kollenstam|first4=Cecilia|last5=Buhrman|first5=Monica|last6=Kaldo|first6=Viktor|last7=Söderberg|first7=Marie|last8=Ekselius|first8=Lisa|last9=Andersson|first9=Gerhard|title=Treatment of panic disorder: live therapy vs. self-help via the Internet|journal=Behaviour Research and Therapy|volume=43|issue=10|year=2005|pages=1321–1333|issn=00057967|doi=10.1016/j.brat.2004.10.002}}</ref>
*Virtual Reality Exposure (VRE) has been found to be effective for both short and long-term management of panic disorder.<ref name="BotellaGarcía-Palacios2007">{{cite journal|last1=Botella|first1=C.|last2=García-Palacios|first2=A.|last3=Villa|first3=H.|last4=Baños|first4=R. M.|last5=Quero|first5=S.|last6=Alcañiz|first6=M.|last7=Riva|first7=G.|title=Virtual reality exposure in the treatment of panic disorder and agoraphobia: A controlled study|journal=Clinical Psychology & Psychotherapy|volume=14|issue=3|year=2007|pages=164–175|issn=10633995|doi=10.1002/cpp.524}}</ref>


==Brain Stimulation Therapy==
==Monitoring response to therapy==
1. Panic Disorder Severity Scale–Self-Report (PDSS-SR)<ref name="pmid31349178">{{cite journal| author=Forsell E, Kraepelien M, Blom K, Isacsson N, Jernelöv S, Svanborg C | display-authors=etal| title=Development of a very brief scale for detecting and measuring panic disorder using two items from the Panic Disorder Severity Scale-Self Report. | journal=J Affect Disord | year= 2019 | volume= 257 | issue=  | pages= 615-622 | pmid=31349178 | doi=10.1016/j.jad.2019.07.057 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31349178  }} </ref>.
# Panic frequency
# Distress during panic
# Anticipatory anxiety
# Avoidance, agoraphobic
# Avoidance, physical
# Work Impairment
# Social Impairment


==Cost Effectiveness of Therapy==
2. The Brief Panic Disorder Severity Scale–Self-Report can also be used for diagnosis<ref name="pmid31349178">{{cite journal| author=Forsell E, Kraepelien M, Blom K, Isacsson N, Jernelöv S, Svanborg C | display-authors=etal| title=Development of a very brief scale for detecting and measuring panic disorder using two items from the Panic Disorder Severity Scale-Self Report. | journal=J Affect Disord | year= 2019 | volume= 257 | issue=  | pages= 615-622 | pmid=31349178 | doi=10.1016/j.jad.2019.07.057 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31349178  }} </ref>. Two items from the PDSS-SR:<br/>
# <li value="2">Distress during panic</li>
# <li value="4">Avoidance, agoraphobic</li>


==Future of Investigational Therapies==
Cutoffs to define meaningful change are not clear.


==References==
==References==
{{reflist|2}}
{{reflist|2}}
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vatsala Sharma; M.B.B.S[2] Kiran Singh, M.D. [3] Yashasvi Aryaputra[4]


Synonyms and keywords: Fit of terror, spasm, anxiety disorder

Overview

Panic disorder is an anxiety condition characterized by recurring panic attacks with significant behavioral change or at least a month of ongoing worry about having another attack. Panic disorder patients have a series of episodic severe anxiety, known as panic attacks. These attacks typically last 10 minutes, however, they can be of shorter duration. They may vary in intensity and symptoms over a period of time. Symptoms of panic disorder commonly present in the form of rapid heart beat, perspiration, dizziness, dyspnea, tremors, uncontrollable fear or feeling of impending doom. The panic attacks often result in embarrassment and social stigma, ultimately resulting in social isolation. Therefore, most of the individuals with panic disorder also develop agoraphobia. If not treated, somatic symptoms like insomnia and/or anorexia develop, which may eventually result in clinical depression and suicide. So, early, efficient, and affordable treatment options should be encouraged.

Historical Perspective

  • Panic disorder has a long history, dating back to folklores.
  • Greek mythology includes one of the examples. The term 'Panic' originated from the Greek god, pan who was responsible for anxiety.[1]
  • In Greek myths, 'pan' was a man with horns and legs of a goat. His mere appearance was so frightening that it developed irrational fear in people, without any apparent reason. This came to be known as panic attacks or terrors. [1]
  • Fear of meeting pan once more stopped the travelers from going to the market. In Greek, agora stands for market and this led to the development of a new term 'agoraphobia'. It stands for the fear of public places or large open spaces.[1]
  • In 1621, Burton described different varieties of pathological anxiety. He related the anxiety to delirium, depersonalization, hypochondria, hyperventilation, and phobias.[1]
  • In 1812, Benjamin Rush (father of American psychiatry), described the relation between somatic causes and phobias in his book. He established an association between depression and hypochondriasis. [1]
  • In 1879, Henry Maudsley used the term panic for the first time in psychiatry, and also explained melancholic panic.[2]
  • Sigmund Freud, in the year 1925, described anxiety neurosis. He separated it from neurasthenia and further elaborated anxiety neurosis with a particular clinical presentation.[1]
  • In 1964, Klein proposed three types of panic attacks: situational (related to agoraphobia), spontaneous, and in response to a stimulus (like height, animals, etc.). [1]

Classification

  • In 1980, panic disorder was first described in DSM-III, based on Klein's description of panic attacks.[1] [3]
  • In 1987, after consistent work on DSM for the next seven years, DSM-III-R described agoraphobia as a consequence of panic disorder. So, agoraphobia was divided into 'panic disorder with and without agoraphobia'.[1]
  • In 1992, DSM-IV described panic attacks related to other conditions. The criteria for panic disorder was not required to be fulfilled here.[1]
  • The criteria for panic disorder remained the same in the revised version of DSM-IV (DSM-IV-TR), published in 2000.[1]
  • DSM-5 has unlinked panic disorder and agoraphobia. [4]
  • The tenth edition of International Classification of Diseases (ICD-10) describes agoraphobia as a distinct condition that may not occur with panic attacks.[1]

Pathophysiology

  • Multiple factors are associated with the pathophysiology of panic disorder.
  • Imbalance of neurobiological, neuroanatomic, and neurochemical factors lead to the production of this condition.
  • Pathogenesis of Panic Disorder is related to the amygdala, the center for fear processing. MRI studies have further substantiated this finding by showing lesser left and right-sided amygdalar volumes in panic disorder patients as compared to controls. [5][6]
  • There is dysregulation of the prefrontal cortex as well as the subcortical components.[7]
  • The patients with panic disorder have more noradrenergic neuronal activity than controls. [8]
  • Another neurochemical theory proposes that these patients have deficient serotonergic inhibition of neurons in the dorsal periaqueductal gray matter of the midbrain and the rostral ventrolateral medulla. [9]
  • The endogenous opioids buffer the panic attacks in normal subjects and their deficit results in the development of the panic disorder. [9]
  • Panic disorder patients have also been found to have lower occipital cortex GABA levels. Other studies suggest dysfunction of GABA(A) receptors in the pathophysiology of panic disorder. This is further supported by improvement in symptoms by treatment focused on GABA binding site of the GABA(A) and benzodiazepine receptor complex. [10][11]

Differential Diagnosis

There are some medical and psychiatric conditions with symptoms mimicking panic disorder: [12][13]

  • Other mental disorders with panic attacks

Epidemiology and Demographics

Prevalence

  • The prevalence of the panic disorder is 2,000-3,000 / 100,000 (2%-3%) of the overall population.
  • 2.7-7.1% of the general population suffers from a lifetime prevalence of panic disorder. [3] [13]

Gender

  • Women are twice as likely as men to develop panic disorder. [14]
  • For both men and women, panic disorder has similar age of onset. Preceding premorbidity was found to be different for men and women.[15]
  • Men had higher rates of body dysmorphic disorder, cyclothymia, and depersonalization preceding panic disorder. Whereas, women had higher rates of bulimia nervosa. Life stressors played a significant precipitating factor for women. [15]

Age

  • Anticipation is characterized by the decrease in age at onset and/or the increase in severity of a disorder in successive generations. It helps in exploring the genetic basis of some diseases.
  • Anticipation is responsible for the familial aggregation of panic disorder. [16]
  • There is an increased risk of disease in the relatives of panic disorder patients with age of onset 20 years or less. The age of onset is useful in determining the familial subtypes. [17]

Race

  • Various studies presented with mixed results.
  • A study comparing the White, African American, Asian, and Latino groups found that the Whites had higher rates of panic disorder, as compared to the African American, Latino, and Asian groups.[18]

Risk Factors

Several factors can increase the chances of Panic Disorder: [19][13]

  • Interpersonal stressors
  • Stressors related to physical well-being

Natural History, Complications, and Prognosis

  • Anxiousness in people with panic disorder begins in childhood due to traumatic life events or distressing family conditions.[20]
  • Family history and genetics play a very important role in the development of panic disorder.
  • Poor prognostic factors are:[21][22][23][24][25]
  • Female gender
  • Comorbid agoraphobia
  • Comorbid depression
  • Comorbid personality disorder
  • Higher oxidative stress index and higher ceruloplasmin level
  • Catastrophic agoraphobic cognitions
  • Panic disorder patients with non-suppression on Dexamethasone Suppression Test (DST)

Diagnostic Criteria

DSM-5 Diagnostic Criteria for Panic Disorder[13]

  • A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or discomfort that reaches a peak within minutes, and associated with at least four of these symptoms:

Note: The abrupt surge can occur from a calm state or an anxious state.

  • 1. Palpitations
  • 2. Sweating
  • 3. Trembling
  • 4. Shortness of breath
  • 5. Feeling of choking
  • 6. Chest pain or discomfort
  • 7. Nausea or abdominal distress
  • 8. Feeling dizzy, or unsteady
  • 9. Chills or sensation of heat
  • 10. Paresthesias (numbness or tingling sensations)
  • 11. Derealization (feelings of unreality) or depersonalization (being detached from oneself)
  • 12. Fear of losing control
  • 13. Fear of dying

Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable screaming or crying) may occur. Such symptoms should not be included as one of the four required symptoms.

AND

  • B. At least one of the attacks has been followed by a minimum of 1 month of the following:
  • 1. Persistent worries about having another panic attack or the consequences (like losing control).
  • 2. A major maladaptive behavioral change in relation to the attacks (behaviors to avoid having panic attacks).

AND

  • C. The disturbance is not due to the effects of a substance or another medical condition.

AND

  • D. The disturbance is not better explained by another mental disorder or due to separation from attachment figures.

Diagnosis in practice

Brief, screening and diagnostic surveys have been reviewed by the United States Preventive Services Task Force (USPSTF)[26].

The draft USPSTF guideline recommends screening[27].

1. The Brief Panic Disorder Severity Scale–Self-Report (Brief PDSS-SR) can also be used for diagnosis[28]:

  • Two items (questions 2 and 4 from the Panic Disorder Severity Scale - Self Report (PDSS-SR)
    • 2. Distress during panic: "If you had any panic attacks during the past week, how distressing (uncomfortable, frightening) were they while they were happening? (If you had more than one, give an average rating. If you didn't have any panic attacks but did have limited symptom attacks, answer for the limited symptom attacks.)
    • 4. Avoidance, agoraphobic: "During the past week were there any places or situations (e.g., public transportation, movie theaters, crowds, bridges, tunnels, shopping malls, being alone) you avoided, or felt afraid of (uncomfortable in, wanted to avoid or leave), because of fear of having a panic attack? Are there any other situations that you would have avoided or been afraid of if they had come up during the week, for the same reason? If yes to either question, please rate your level of fear and avoidance this past week."
  • Sum of 3 or more points[28]:

2. Panic Disorder Severity Scale–Self-Report (PDSS-SR)[28]:

  • Cutoff cutoff ≥9:
    • Sensitivity of 67% to 83%
    • Specificity of 64% to 96%
    • Gain in certainty (Sensitivy + specifity)[29] 1.5 (0.75 + 0.79)

3. PHQ-PD[30]:

  • Criteria: questions #3a-d are all YES and 4 or more of #4a-k are YES:

4. GAD-7

Treatment

  • Panic Disorder is a potentially disabling condition but can be successfully treated.
  • Due to the disturbing symptoms that accompany the panic disorder, it can be mistaken for a life-threatening physical illness.
  • Thorough investigation to rule out the suspected medical condition and early initiation of treatment should be the ultimate goal of managing the panic disorder.
  • Panic disorder can be treated by medications, psychotherapy, or both.
  • A skilled treating team of psychiatrists, psychologists, and social workers is required for this purpose.

Medications

  • SSRIs such as paroxetine, escitalopram, and citalopram, are used for maintenance therapy. [31][32]
  • MAOIs are usually avoided because of the life-threatening side effects such as serotonin syndrome, hypertensive crisis, and other drug interactions.
  • TCAs are associated with anticholinergic side effects, so avoided in the elderly.
  • Both SSRIs and TCAs are effective for the treatment but SSRIs are preferred because of a better tolerability profile.[33]
  • These are used for a short duration to control the acute phase of illness or given until the SSRIs have achieved therapeutic action.
  • Long-term use is not advisable because of the high chances of developing dependence and drug-seeking behavior.

Psychotherapy

  • There are multiple treatment options available such as exposure to somatic cues, cognitive behavior therapy (CBT), and relaxation therapy for panic disorder. When combined, these management options provide the best results.
  • Exposure to somatic cues and CBT, when combined result in nearly 85% response rate. [34]
  • Relaxation techniques produce greater reduction in the associated anxiety but are related to higher drop-out rates. [34]
  • CBT can also be administered in the form of group therapy. It is found to be equally effective as pharmacotherapy in some studies.[35]
  • CBT comprises of: [35]
  • Education and corrective information
  • Cognitive therapy
  • Training in diaphragmatic breathing
  • Interoceptive exposure

Other treatment modalities

  • Regular aerobic exercise alone has been associated with clinical improvement in patients with panic disorder but is lesser effective than pharmacotherapy. [36]
  • When properly used, Internet-based self-help programs with minimal therapist contact can be equally efficacious as traditional individual CBT. [37]
  • Virtual Reality Exposure (VRE) has been found to be effective for both short and long-term management of panic disorder.[38]

Monitoring response to therapy

1. Panic Disorder Severity Scale–Self-Report (PDSS-SR)[28].

  1. Panic frequency
  2. Distress during panic
  3. Anticipatory anxiety
  4. Avoidance, agoraphobic
  5. Avoidance, physical
  6. Work Impairment
  7. Social Impairment

2. The Brief Panic Disorder Severity Scale–Self-Report can also be used for diagnosis[28]. Two items from the PDSS-SR:

  1. Distress during panic
  2. Avoidance, agoraphobic

Cutoffs to define meaningful change are not clear.

References

  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 Nardi, Antonio Egidio (2006). "Some notes on a historical perspective of panic disorder". Jornal Brasileiro de Psiquiatria. 55 (2): 154–160. doi:10.1590/S0047-20852006000200010. ISSN 0047-2085.
  2. Nardi, Antonio Egidio; Freire, Rafael Christophe R. (2016). "The Panic Disorder Concept: A Historical Perspective": 1–8. doi:10.1007/978-3-319-12538-1_1.
  3. 3.0 3.1 Angst J (1998). "Panic disorder: History and epidemiology". Eur Psychiatry. 13 Suppl 2: 51s–5s. doi:10.1016/S0924-9338(98)80014-X. PMID 19698673.
  4. Roest, Annelieke M.; Vries, Ymkje Anna; Lim, Carmen C. W.; Wittchen, Hans‐Ulrich; Stein, Dan J.; Adamowski, Tomasz; Al‐Hamzawi, Ali; Bromet, Evelyn J.; Viana, Maria Carmen; Girolamo, Giovanni; Demyttenaere, Koen; Florescu, Silvia; Gureje, Oye; Haro, Josep Maria; Hu, Chiyi; Karam, Elie G.; Caldas‐de‐Almeida, José Miguel; Kawakami, Norito; Lépine, Jean Pierre; Levinson, Daphna; Medina‐Mora, Maria E.; Navarro‐Mateu, Fernando; O’Neill, Siobhan; Piazza, Marina; Posada‐Villa, José A.; Slade, Tim; Torres, Yolanda; Kessler, Ronald C.; Scott, Kate M.; Jonge, Peter (2019). "A comparison of DSM ‐5 and DSM ‐IV agoraphobia in the World Mental Health Surveys". Depression and Anxiety. 36 (6): 499–510. doi:10.1002/da.22885. ISSN 1091-4269. line feed character in |title= at position 16 (help)
  5. Kim, Jieun E; Dager, Stephen R; Lyoo, In Kyoon (2012). "The role of the amygdala in the pathophysiology of panic disorder: evidence from neuroimaging studies". Biology of Mood & Anxiety Disorders. 2 (1): 20. doi:10.1186/2045-5380-2-20. ISSN 2045-5380.
  6. Massana, Guillem; Serra-Grabulosa, Josep Maria; Salgado-Pineda, Pilar; Gastó, Cristòbal; Junqué, Carme; Massana, Joan; Mercader, José Maria; Gómez, Beatriz; Tobeña, Adolf; Salamero, Manel (2003). "Amygdalar atrophy in panic disorder patients detected by volumetric magnetic resonance imaging". NeuroImage. 19 (1): 80–90. doi:10.1016/S1053-8119(03)00036-3. ISSN 1053-8119.
  7. Coplan, Jeremy D; Lydiard, R.Bruce (1998). "Brain circuits in panic disorder". Biological Psychiatry. 44 (12): 1264–1276. doi:10.1016/S0006-3223(98)00300-X. ISSN 0006-3223.
  8. "Neurobiological mechanisms of panic anxiety: biochemical and behavioral correlates of yohimbine-induced panic attacks". American Journal of Psychiatry. 144 (8): 1030–1036. 1987. doi:10.1176/ajp.144.8.1030. ISSN 0002-953X.
  9. 9.0 9.1 Graeff, Frederico G. (2017). "Translational approach to the pathophysiology of panic disorder: Focus on serotonin and endogenous opioids". Neuroscience & Biobehavioral Reviews. 76: 48–55. doi:10.1016/j.neubiorev.2016.10.013. ISSN 0149-7634.
  10. Goddard, Andrew W.; Mason, Graeme F.; Almai, Ahmad; Rothman, Douglas L.; Behar, Kevin L.; Petroff, Ognen A. C.; Charney, Dennis S.; Krystal, John H. (2001). "Reductions in Occipital Cortex GABA Levels in Panic Disorder Detected With 1H-Magnetic Resonance Spectroscopy". Archives of General Psychiatry. 58 (6): 556. doi:10.1001/archpsyc.58.6.556. ISSN 0003-990X.
  11. Rupprecht, R.; Zwanzger, P. (2003). "Die Bedeutung von GABAA-Rezeptoren f�r Pathophysiologie und Therapie der Panikst�rung". Der Nervenarzt. 74 (7): 543–551. doi:10.1007/s00115-002-1433-x. ISSN 0028-2804. replacement character in |title= at position 37 (help)
  12. Edlund, Matthew J.; McNamara, M.Eileen; Millman, Richard P. (1991). "Sleep apnea and panic attacks". Comprehensive Psychiatry. 32 (2): 130–132. doi:10.1016/0010-440X(91)90004-V. ISSN 0010-440X.
  13. 13.0 13.1 13.2 13.3 Diagnostic and statistical manual of mental disorders : DSM-5. Washington, D.C: American Psychiatric Association. 2013. ISBN 0890425558.
  14. "Facts about Panic Disorder". National Institute of Mental Health. Retrieved 2006-09-30.
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