Panic Attacks (PAs) and Panic Disorder (PD)

INTRODUCTION

Panic attacks (PAs) have been recorded throughout human history but first mentioned in medical literature during the early eighteenth century and established as a psychiatric diagnosis in the 1980's. Today, a PA is described as a discrete period of intense fear or discomfort accompanied by at least four of the thirteen symptoms listed in Table 1. The most frequent symptoms of a PA are palpations (73%), dizziness (61%), shortness of breath (37%), trembling and shaking (37%).

A PANIC ATTACK (PA)

A PA peaks in ten minutes, lasts for thirty minutes, occasionally longer. Following an attack, less intense or distressing feelings may continue for hours, often accompanied by a sense of weakness, fatigue and apprehension over a further attack. The frequency of PAs varies widely, some experience PAs daily, others intermittently or only on exposure to fearful situations. Studies show that 7.3 to 10.5% of the population will experience a PA sometime in their life.

The first attack ought not be ignored: it is often the tip of the iceberg. Ninety - nine percent will have depressive and anxiety symptoms at the time of the first attack. Following the first attack, 69% develop panic disorder while for 51% the outcome will be major depression and panic disorder with agoraphobia. Panic attacks occur in any age group, including children and are more common in females.

TYPES OF PANIC ATTACKS (PAs)

Those who suffer PAs may experience one or more of the types listed below. Regardless of type, they are fearful events, the fearfulness often recalled.

Spontaneous (un - cued, unexpected) panic attacks
Spontaneous PAs occur in the absence of a trigger. They are a fearful surprise for the sufferer and often the first type of panic attack experienced.

Situational (cued) panic attacks
Situational PAs occur on exposure to the situation that one is phobic about. Prior to entering the phobic situations, anxiety known as anticipatory anxiety is experienced; the cause of this anxiety is whether a PA will occur. Situational PAs occur in a number of anxiety disorders including panic disorder with agoraphobia, social anxiety disorder, specific phobia, obsessive compulsive disorder and post traumatic stress disorder.

Situational predisposed panic attacks
Situational predisposed PAs are not necessarily related to a cue, in that, the attack may or may not happen on exposure to a feared situation.

Limited symptom attacks
Limited symptom attacks are PAs in which there are fewer than four symptoms. The symptoms are similar to the full - blown attacks but are perceived as less intense. It is rare to experience limited symptom attacks in the absence of full - blown attacks.

Nocturnal panic attacks (NPAs)
NPAs refer to wakening in a state of panic one to three hours after sleep onset. The attacks last from two to eight minutes and the symptoms are similar to daytime panic but often more severe. Up to two thirds of those with panic disorder, at sometime, experience a NPA and one third will have such attacks regularly. Some experience a NPA in the absence of a daytime PA. Following a NPA, a delay in returning to sleep is the norm.

Relaxation induced panic attacks
Surprisingly, PAs can occur even in relaxed, hypnotic or trance like states; these attacks are most common in those who are highly anxious and worrisome. Underlying these attacks is the fear of loss of control and/or the misinterpretation of body sensations that occur as these states are achieved. The changes in body sensations are interpreted as signs of an oncoming panic attack.

PANIC DISORDER (PD)

The diagnosis of panic disorder is made when the individual experiences:

A. Recurrent, unexpected panic attacks.

B. At least one of the attacks is followed by one month or more of the following:

• Persistent concerns about having an additional attack
• Worrying about implications of the attack
• A significant change in behaviour related to the attack, i.e., avoidance of situations

PANIC DISORDER WITH AGORAPHOBIA

Panic disorder (PD) is more likely to occur in women than in men. One third to one half of those with PD develop agoraphobia, the onset of which is within the first year of recurrent PAs. The defining feature of agoraphobia is concern about experiencing a PA while being in situations where escape is not possible or assistance unavailable in the event of a PA. Situations are thus avoided for a fear of a PA. If the phobic situation is to be entered, anticipatory anxiety occurs. While in the situation, the person experiences distress, is vigilant about a PA occurring and becomes aware of escape routes in case an attack occurs. Some will enter the phobic situation with a person they trust, experience no panic and feel less distressed. The most common agoraphobic fears are listed in Table 2.

PANIC DISORDER DOES NOT OCCUR ALONE

Sixty - five percent of those with PD have further diagnoses with mood disorders the most common and dysthymia, a chronic flatness of mood, being more common than major depression. Lifetime prevalence rates of the mood disorders with PD, range from 63 - 68%, the episodes occurring separately, simultaneously or as a complementing factor of the other. When past or present mood disorders are confirmed, PD is often more chronic, disabling and the phobic anxiety more severe. Many with PD experience symptoms of a mood disorder but do not reach the diagnostic criteria for such a disorder; the symptoms however are debilitating. Studies show that suicidal ideation and suicide attempts are higher in PD than other psychiatric disorders. Up to 20% of those with PD will attempt suicide.

Many with PD also have a co - occurring anxiety disorder, the onset likely to have preceded the onset of PD. Up to 47% report specific phobia and 30% report social anxiety disorder. The use of alcohol as a mode of self - medication is common, up to 82% report, at times, having used alcohol to cope and most (72%) consider it effective in alleviating their anxiety. Twenty - two percent with PD develop alcohol or substance abuse disorders and 40 - 70% may have a personality disorder. A personality disorder is defined as an enduring illness, characterised by a set of inflexible and maladaptive traits that lead to significant distress for the sufferer. Where there is a co-occurring illness, recovery from PD is often slower.

Return to the Panic Anxiety Mood Guide home page to learn more about the above psychiatric illnesses.

Click here for Treatments