FYI - for those interested in panic disorder
Introduction
Anxiety disorders are the most common, or frequently occurring, mental disorders. International studies indicate lifetime prevalence rates for panic disorder, in the range of 1.5% to 3.5% of the general population (McLean and Woody, 2001). Panic disorder affects about 1.7% of the adult U.S. population aged 18 to 54, which represents approximately 2.4 million Americans in a given year (National Institute of Mental Health [NIMH], 2003). Panic disorder represents a subset of anxiety disorders, and can occur with agoraphobia or without agoraphobia. Agoraphobia is a condition in which the person becomes afraid of any place or situation in which escape might be difficult or help is unavailable in the event of a panic attack.
According to the Diagnostic and Statistical Manual: Fourth Edition, Text Revision, a Panic attack is identified as a discrete period of intense fear or discomfort in the absence of real danger that is accompanied by at least 4 of 13 somatic or cognitive symptoms (American Psychological Association [APA], p. 430, 2000). These symptoms include palpitations, sweating, trembling/shaking, sensations of shortness of breath or smothering, feeling of choking, chest pain/discomfort, nausea/abdominal distress, dizziness/lightheadedness, derealization/depersonalization, fear of losing control/going crazy, fear of dying, paresthesias, and chills/hot flushes. Panic attacks have sudden onset and generally peak within a 10-minute period. They are often accompanied by feelings of imminent danger or impending doom and include an urge to escape (APA, 2000). Attacks that contain less than the required 4 symptoms are referred to as limited-symptom attacks.
Panic attacks, while being a central feature to panic disorder, can occur without a diagnosis of panic disorder being made. Generally speaking, there are 3 types of panic attacks: Unexpected (appear of the blue), situationally bound (attacks are almost invariably associated with a situational cue or trigger), and situationally predisposed (attacks are associated with a situational cue or trigger, but not always noted with that cue or trigger) (APA, 2000). Panic Attacks can occur in the context of any Anxiety Disorder as well as other mental disorders (e.g., Mood Disorders, Substance-Related Disorders) and some general medical conditions (e.g., cardiac, respiratory, vestibular, gastrointestinal)
(APA, p. 430, 2000).
A diagnosis of panic disorder DOES require the presence of recurrent Unexpected-type panic attacks, where the individual does not associate an onset with a particular internal or external situational trigger (APA, 2000). Furthermore, the individual must have at least 1 month of persistent concern about either having another attack, worrying about the consequences of the attacks or significantly changing their behavior as a result of the attacks (APA, 2000). Finally, the counselor must rule out the direct effects of a substance (such as cocaine, caffeine, etc.), general medical conditions (such as hyperthyroidism, etc.) and other mental disorders that may better account for the presenting symptoms and signs noted by the counselor (such as Social Phobia, Specific Phobias, etc.).
Individuals with panic disorder also tend to have the remaining two types of panic attacks - situationally cued or predisposed panic attacks - also (APA, 2000). Additionally, the presence of limited-symptom attacks (similar to full panic attacks except less than four symptoms are noted) is also common in individuals with panic disorder. Barlow, Craske, and Meadows (2000) discuss a cycle which seems to occur in that the individual with panic disorder learns a fear of fear, in which their heightened sensitivity to unpredictable changes in their bodys internal states and misappraisals of their body sensations creates high levels of chronic anxious apprehension and maintains anticipatory anxiety about the recurrence of a panic attack, which, in turn, increases the likelihood of a panic attack due to the increasing availability of sensations that have become conditioned cues for a panic attack or by increasing their attention to their bodys cues.
Comorbidity with other anxiety disorders (Social Phobia, Generalized Anxiety Disorder, Specific Phobia, Obsessive-Compulsive Disorder, Posttraumatic Stress Disorder, Major Depressive Disorder, Substance-Related Disorder, Separation Anxiety Disorder in childhood, and Hypochondriasis are noted (APA, 2000). Additionally, comorbidity with numerous medical symptoms/conditions (hyperthyroidism, asthma, dizziness, cardiac arrhythmias, chronic obstructive pulmonary disease, and irritable bowel syndrome) is noted, but no cause-effect relationship between the presence of panic disorder and these medical challenges are identified at this time (APA, 2000). Women are twice as likely to develop the disorder, and appearance of symptoms typically arises in young adulthood, with roughly half of the people who have this problem developing the condition before 24 years of age (NIMH, 2003). There may be a bimodal distribution, with one peak in late adolescence and a second, smaller peak in mid 30 year olds (APA, 2000). Onset after age 45 is considered unusual of this disorder, but it can occur (APA, 2000).
Agoraphobia can represent a more advanced stage of panic disorder and affects about one-third of individuals diagnosed with panic disorder (NIMH, 2001). While agoraphobia may develop at any point within or outside of a panic disorder, it generally develops within the first year of occurrence of recurrent panic attacks (APA, 2000) and the likelihood of a person developing agoraphobia increases as the individuals history of panic attacks lengthens (Barlow et al., 2000). Interestingly enough, the age of onset or the frequency of panic attacks is not associated with the development of agoraphobia (Barlow et al., 2000).
Etiology
The exact causes of panic disorder are currently unknown, but heredity and other biological events such as stressful life events or thinking in a manner that exaggerates physiological reactions to typical events seem to play some role in its formation (NIMH, 1999). Panic disorder tends to run in families. Information obtained from twin studies indicates that identical twins are more likely to get panic disorder than fraternal twins (NIMH, 2001). First-degree relatives are 8 times more likely to get the disorder when compared to the general population (APA, 2000). There are two main viewpoints pertaining to the etiology of this disorder.
The cognitive-behavioral theorists focus on possible disturbances in the individuals coping mechanisms due to repeated life stresses interacting in tandem with a genetic or learned predisposition towards having this disorder. According to Barlow et al. (p. 23, 2000), Anxiety sensitivity may be acquired unknowingly from a lifetime of direct experiences such as a personal history of significant illness or injury, exposure to significant illnesses or death among family members, or association with family members who display a fear of physical sensations through hypochondriasis. Additionally, heightened anxiety sensitivity may be created by informational disclosures, such as parental warnings or overprotectiveness regarding physical well being (Barlow et al., 2000). These warnings from other adults may serve to sensitize the panic-prone individual further, as these expressed concerns would validate this persons feelings or serve to increase the perceived danger of typical situations or events.
According to Barlow et al. (2000), a stress-diathesis interaction seems to account for initial panic attacks. Substantiating this view is the following statement from the National Institute of Mental Health.
Initial panic attacks may occur when people are under considerable stress, from an overload of work, for example, or from the loss of a family member or a close friend. The attacks may also follow surgery, a serious accident, illness, or childbirth. Excessive consumption of caffeine or the use of cocaine or other stimulant drugs or medicines, such as the stimulants used in treating asthma, can also trigger panic attacks (NIH, p. 2, 2001).
The neurobiological theorists focus on whether people with panic disorder have a low tolerance for normal physiological and psychological response to stress that is, their bodys alarm goes off with little to no provocation (NIMH, 1999). The hypothesis is that their body has learned to perceive normal events as being dangerous, giving rise to a false alarm. Research focusing on the provocation of panic attacks indicates that a panic attack can be provoked using carbon dioxide, hyperventilation, caffeine, or sodium lactate (natural chemical that increases in muscles during heavy exercise) in people who have panic disorder, but not in people who do not have the disorder (Butcher, Carson and Mineka, 2002). The fact that people who have been diagnosed as having panic disorder - and therefore a predisposition to have a panic attack due to prior history - can be biologically manipulated to have a panic attack in a laboratory setting, and that people without this predisposition cannot be biologically provoked to such attacks, indicates that both strong psychological and biological factors are at play. This causal relationship between the individual who has panic attacks and the predictable causation of these attacks through biological manipulation continues to be an area of investigation (NIMH, 2001).
