Panic Disorder and Panic Attacks: Causes, Origins, Mechanisms, Treatment
What is a Panic Attack?
A panic attack is an abrupt, often unanticipated outbreak of severe anxiety, the treatment of which can be complicated by the presence of comorbid conditions. Panic attacks typically co-occur with some physical symptoms (e.g. shortness of breath, racing heartbeat, muscle tension, trembling and dizziness).
Panic Attacks in Panic Disorder and Co-occurrence with Agoraphobia
The main symptom of panic disorder is recurring panic attacks that are usually striking in their initial manifestation. Panic attacks interfere with daily functioning and could be disabling and progressive, especially if combined with agoraphobia. At the core of agoraphobia is the fear of being unable to escape from a certain place or situation or seek aid in a panic attack.
DSM-V Diagnostic Criteria of Panic Disorder
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), to be diagnosed with panic disorder, an individual must present with recurrent panic attacks along with any of the following symptoms:
- Worrying about the likelihood of forthcoming attacks.
- Developing agoraphobic avoidance—i.e. staying away from situations or places in which the person fears could provoke a panic attack. In places where fleeing or getting help during a panic attack would be impossible or problematic. For example, driving on a bridge, staying in a crowded place and using an elevator.
- Other behaviours due to the attacks (e.g. visits to the doctor or emergency room because of worries about an undiagnosed medical condition).
Panic Attacks in Other Disorders
However, panic attacks do not necessarily ”belong” to panic disorder. The same pattern of physical and cognitive symptoms can be observed in individuals with specific phobias when faced with the feared stimulus (e.g. spiders, snakes, heights, dogs, etc.) or in those with social phobia when exposed to situations where others may evaluate them. The difference in such circumstances is that the person is aware of the source of their fears. In contrast, in panic disorder, these same types of symptoms are unprovoked, inexplicable, and often arise out of the blue.
Moreover, panic attacks can occur in individuals with post-traumatic stress disorder, for whom exposure to cues of a traumatic incident can cause attacks and can be especially difficult to differentiate as such unless a careful history of earlier traumatic experiences is detailed.
Co-Occurrence of Some Physical Conditions
Furthermore, the co-occurrence of some physical conditions, such as cardiovascular (e.g. tachycardia), respiratory (e.g. asthma and chronic obstructive pulmonary disease) and otological (e.g. Meniere’s disease) increases with panic disorder. However, these conditions are rarely a direct cause of panic attacks. In addition, panic attacks can also be a sign of common conditions such as caffeine and stimulant use or abuse (e.g., cocaine, methamphetamines) and hyperthyroidism.
Origins of Panic Attacks
Many epidemiological studies have explored risk factors for panic disorder. As with most psychiatric conditions, a vulnerability-stress model generally explains the origin and maintenance of the disorder. The model claims that the cause of a psychological condition, including panic disorder, is an interaction between genetic predisposition and environmental stress factors. Twin studies indicate a heritability of panic disorder of about 40%. Research points out that early life traumatic experiences are a significant risk factor, along with an anxious personality characterised by anxiety sensitivity and neuroticism. Furthermore, certain lifestyles (e.g. smoking) raise the risk for panic disorder.
Genetic susceptibility
Panic disorder, like other psychiatric disorders, is a complex condition with different genes conferring susceptibility through unidentified pathways. Panic might be present in various genetic forms, each with a distinct set of genes. It could also exist in a single form with underlying genes reflecting a wide vulnerability to anxiety and panic.
Chromosome 13
Research evidence supports a specific form of panic disorder related to bladder problems linked to chromosome 13. An association study also related this chromosome to panic disorder, regardless of associated features.
Chromosome 18
A subtype of bipolar disorder linked to panic attacks has been linked to chromosome 18. This subtype might display clinical differences from other types of bipolar disorder (i.e. rapid mood alterations and higher familial risk for affective disorders).
Chromosome 9q31
Furthermore, a genome-wide study of an Icelandic cohort discovered a linkage on chromosome 9q31 also related to cigarette smoking. This region is noteworthy because of the formerly established association between adolescent smoking and adult risk of panic disorder.
Adenosine 2A Receptor Gene
Finally, research has linked the adenosine 2A receptor gene to panic disorder, revealing that variations in the gene have been related to caffeine-induced anxiety.
Anxiety Sensitivity
Factors that intensify the sensitivity to physical sensations are fundamental in the onset of panic disorder. Anxiety sensitivity refers to the belief that anxiety could lead to harmful psychological, social and physical consequences. Anxiety sensitivity could be developed perniciously from direct aversive experiences, and it may be learned vicariously, via observation and imitation. In addition, parental encouragement of attention to bodily symptoms or parental modelling of troubled reactions to physical sensations may contribute to its development. Ultimately, panic attacks themselves intensify anxiety sensitivity. The prevalence between ages 15 and 19 can be possibly explained by the increased sensitivity to physical cues at that period of psychosocial development, which may be related to hormonal changes and sexual maturation.
Maintenance of Panic Attacks
Critical fear of fear that progresses after the first panic attacks may develop for two reasons. The first reason is interoceptive conditioning or conditioned fear of internal signals (e.g. increased heart rate). In this model, minor alterations in corporal functions that individuals might not be cognisant of can provoke conditioned fear and panic because of earlier associations with the fear of panic.
The second reason is catastrophic misinterpretations of bodily sensations (e.g. loss of control or imminent death). Catastrophic misinterpretations can be subconscious (e.g. during panic attacks when sleeping or when disastrous thoughts are not evident). However, in most cases, such catastrophic misappraisals are consciously accessible even if panic attacks are unexpected.
Panic Attack Treatment: Pharmacological Therapy
Pharmacological panic attack therapy helps lessen or get rid of related phobic avoidance, anticipatory anxiety and other symptoms due to comorbid disorders such as major depressive disorder (MDD).
Panic Attack Treatment: Psychological Therapy
Cognitive-behavioural therapy for panic attacks (CBT) is one of the most extensively studied therapies for anxiety disorders, including generalised anxiety disorder (GAD) and social anxiety. It is effectively delivered individually or in a group, online or in person. CBT for panic attacks originates from both cognitive theories and interoceptive conditioning. Consequently, therapists often employ both cognitive and panic control interventions.
Bibliography:
- DOI: 10.1093/med:psych/9780195116250.001.0001
- DOI: 10.1016/s0140-6736(06)69418-x