Panic Disorder

Definition and Diagnosis 

A panic disorder refers to repeated and unexpected panic attacks. A panic attack can be described as the sudden onset of overwhelming fear or acute distress that rapidly intensifies within minutes, during which at least four out of thirteen specified physical and cognitive symptoms manifest. These thirteen symptoms include:

1. Palpitations, pounding heart, or accelerated heart rate.
2. Sweating.
3. Trembling or shaking.
4. Sensations of shortness of breath or smothering.
5. Feelings of choking.
6. Chest pain or discomfort.
7. Nausea or abdominal distress.
8. Feeling dizzy, unsteady, light-headed, or faint.
9. Chills or heat sensations.
10. Paresthesias (numbness or tingling sensations).
11. Derealization (feelings of unreality) or depersonalization (being detached from oneself).
12. Fear of losing control or “going crazy.”
13. Fear of dying.

Moreover, “sudden” or “unexpected” refers here to the attacks occurring without an overt trigger, as they often occur during periods of relaxation or sleep (also known as nocturnal panic attacks). However, there are also “expected” panic attacks, which are indicated by clear triggers, occurring in situations that are associated with panic. Whether an attack is characterized as expected or unexpected is determined by physicians through detailed questioning of an individual’s perception. It is important to note, however, that most individuals experience both types of attacks; in the U.S. and Europe, about half of those who suffer from panic disorder experience both.

The frequency and severity of panic attacks can also vary significantly. Some individuals may experience moderately frequent attacks (one attack per week), while others may experience attacks daily, followed by a period of no attacks. There is no differentiation between the symptoms, demographics, family histories, and biological data of frequent and infrequent panic attacks.

Concerns about panic attacks often involve fears of physical issues (e.g., cardiac disease), social embarrassment, or mental instability. Also, maladaptive behaviors often develop to avoid panic attacks, such as avoiding physical exertion, reorganizing routines for support, limiting daily activities, and avoiding situations like public transportation or shopping. Although individuals frequently try to avoid agoraphobia-type scenarios, agoraphobia is diagnosed separately.

Features that Support the Diagnosis of Panic Disorder

In the U.S., about 25–33% of individuals with panic disorder experience a nocturnal panic attack in which they wake up in sleep in a state of panic. They are often experienced alongside daytime attacks. Beyond worrying about panic attacks, many with panic disorder have constant or intermittent anxiety about health, fearing catastrophic outcomes from mild symptoms (e.g., believing a headache is a brain tumor). Additionally, they may be intolerant of medication side effects, overly concerned about daily tasks and stressors, misuse drugs to control panic, or adopt extreme behaviors to avoid panic triggers.

Prevalence

The 12-month prevalence of panic disorder in the U.S. and Europe is about 2-3% among adults and adolescents. In the U.S., Latinos, African Americans, Caribbean blacks, and Asian Americans report lower rates than non-Latino whites, while American Indians report higher rates. In Asia, Africa, and Latin America, prevalence ranges from 0.1% to 0.8%. Panic disorder is also more common in females than males at a 2:1 ratio, noticeable before age 14. Prevalence rises during adolescence, especially in females, peaks in adulthood, and declines in those over 64, likely due to less severe symptoms. 

Moreover, a study that included 8,098 respondents aged between 15 and 54 years found that the lifetime prevalence of panic attacks in the U.S. was approximately 15%. Interestingly, the study also stressed how respondents with lower educational attainment were more likely to suffer from panic attacks. A study from 2006 noted similar findings, stating that 3.8% of the respondents suffered a panic attack in the preceding month. However, what this study also highlights is the high comorbidity with other mental health conditions, such as mood disorders, substance use disorders, impulse-control disorders, and other anxiety disorders, including PTSD, OCD, and phobias.

These findings underscore the intricate nature of panic disorder, highlighting significant variances in prevalence across different demographics and its notable comorbidity with other mental health conditions.

Development and Course

In most cases, the onset of panic disorder is between the ages of 20 and 24, although it is also possible to start in childhood or after the age of 45. The course is usually chronic, with symptoms fluctuating in severity. Some experience episodic outbreaks with remissions, while others have continuous symptoms. Full remission without relapse is rare. As has been mentioned in the previous section, panic disorder often co-occurs with other anxiety, depressive, and substance use disorders. In adolescents, it mirrors adult presentation and is frequently comorbid with anxiety, depression, and bipolar disorders. In older adults, symptoms may be less severe due to autonomic response changes, often attributed to specific stressors, leading to potential underdiagnosis.

An interesting study published in 2009 examined the correlation between respiratory manifestations and panic disorder, highlighting that individuals suffering from panic disorder are often more sensitive to CO2. This heightened sensitivity leads to the hypothesis that there are fundamental abnormalities in the physiological mechanisms controlling breathing in patients suffering from panic disorder. Patients with panic disorder frequently hyperventilate and panic in response to respiratory stimulants like CO2, which triggers a hypersensitive fear network. This network involves the hippocampus, medial prefrontal cortex, amygdala, and brainstem projections. The study suggests that panic attacks might be triggered by abnormal respiratory responses, reinforcing the connection between respiratory dysfunction and panic attacks.

Consequently, treatments such as medication and cognitive-behavioral therapy that target these mechanisms are effective.

Risk Factors 

The general causes of panic disorder can be attributed to temporal, environmental, genetic, and psychological factors.

Temporal factors

Negative affectivity, or neuroticism, refers to a tendency to experience negative emotions, which increases the likelihood of panic attacks and associated worries. Although its role in diagnosing panic disorder remains unclear, anxiety sensitivity—the belief that anxiety symptoms are harmful—also heightens the risk of panic attacks and related concerns.

Environmental factors

Childhood experiences of sexual and physical abuse are more frequently reported in individuals with panic disorder compared to other anxiety disorders. Additionally, most individuals can identify significant stressors in the months preceding their first panic attack. These stressors often include interpersonal conflicts, negative experiences with illicit or prescription drugs, illness, or the death of a family member. However, many studies also highlight smoking as an environmental factor.

A study conducted in 1999 analyzed data from two epidemiologic studies and found that daily smoking increases the risk of first-time panic attacks and panic disorder. This risk is higher in active smokers compared to those who have quit. The study also suggests lung disease as a potential mediator in the smoking-panic attack link, which also emphasizes the findings of the studies exploring the correlation between panic attacks and respiratory symptoms, such as the one mentioned in the previous section. 

Genetic and psychological factors

Multiple genes are believed to contribute to vulnerability to panic disorder, though their specific roles are unknown. Neural models highlight the amygdala and related structures. There is a higher risk for panic disorder among children of parents with anxiety, depressive, and bipolar disorders. Respiratory issues like asthma are also linked to panic disorder through history, comorbidity, and family history.

Cultural Differences in Panic Disorder Diagnosis 

Cultural interpretations can affect whether panic attacks are seen as expected or unexpected. Specific symptoms and their frequency vary across cultures. For instance, African Americans report higher rates of paresthesias, while dizziness is more common in several Asian groups. Cultural syndromes like Cambodia’s khyal attacks and Vietnam’s trùnggiô attacks involve unique symptoms. Latin America’s ataque de nervios includes symptoms like trembling and uncontrollable crying. 

Moreover, a study published in the Journal of Anxiety Disorder examined the experience of panic symptoms across a multiracial student sample. Although the overall occurrence of panic symptoms is similar across groups, the specific symptoms vary. Asian participants report more dizziness, unsteadiness, choking, and feelings of terror compared to Caucasians, whereas African Americans report feeling less nervous. Hispanic participants show no significant differences from other groups. The correlation between panic symptoms and severity is stronger for Asians and Caucasians than for African Americans. Such findings stress the importance of considering the cultural context in the assessment of panic symptoms since symptom severity may vary depending on racial group or culture. 

Gender Differences in Panic Disorder Diagnosis 

Although panic attacks occur more commonly in females than males, clinical features or symptoms do not vary between males and females. For example, a study from 2000 explored gender differences in patients with panic disorder, focusing on cognitive factors influencing phobic avoidance. According to the study, females exhibit higher anxiety sensitivity and stronger beliefs in the likelihood and consequences of panic attacks. The study also states that females face a greater risk of developing agoraphobia alongside panic disorder.

However, a study that explored the gender differences in the onset of panic attacks found that women were more likely to have a family history of mood disorders and experience life events, such as separation and conflicts, that trigger panic disorder. Although the study acknowledges that men and women have similar ages of onset of panic disorder, it also stresses that their conditions and triggers differ, highlighting the importance of considering gender-specific factors. 

Cognitive Behavioral Therapy (CBT) and Panic Disorder 

An article from 1997 discussed the effectiveness of CBT for panic disorder. According to the article, CBT for panic disorder typically includes cognitive restructuring, breathing retraining, and interoceptive exposure. Controlled clinical trials showed that CBT yields the highest mean effect size compared to pharmacologic treatments and combined therapies, with a lower dropout rate. However, some patients still experience periodic exacerbations of symptoms.

Additionally, integrating CBT with pharmacologic treatments like SSRIs may improve outcomes, especially in patients with agoraphobia, suggesting a multifaceted approach can enhance long-term results. Moreover, an article from 2005 reviewed the efficiency and application of CBT for panic disorder. The article claims that CBT offers a quick onset of action, long-term maintenance of benefits, and is well-tolerated and cost-effective. Interestingly, the article also states that CBT is effective for patients who have not responded to pharmacotherapy and can positively impact comorbid conditions.

Crucially, another study from 1995 explored how CBT would impact the quality of life of patients who suffer from panic disorder. After undergoing group CBT, patients showed substantial improvements in areas of life in which they had experienced significant impairments beforehand (areas of work, social, and leisure activities). CBT was found to be effective for patients suffering from panic attacks since these gains were maintained after a six-month follow-up. 

How the Sintelly App Can Help

The Sintelly app has a smart CBT therapy chatbot that’s like having a supportive friend available 24/7. If a panic attack strikes, you can chat with the bot for instant, personalized advice. It helps you challenge negative thoughts, regain control, and find calm. You can talk to it about anything, making it a great tool for immediate support.

After finding instant calm Sintelly offers various exercises that use AI to tailor them to your needs. These exercises focus on changing negative thinking, practicing breathing techniques, and facing fears gradually. Doing these exercises helps build long-term coping strategies, reducing the frequency and intensity of panic attacks.

With AI-powered psychodiagnostic tests, the app provides deep insights into your mental health. These tests track your progress, spot early signs of anxiety, and help understand how panic disorder affects you. The feedback from these tests is super useful for you and your healthcare provider to adjust treatments as needed. They also help identify any other mental health issues you might be facing.

You can track your progress over time through graphs and charts. This visual feedback helps you see improvements and stay motivated. It’s a great way to measure how far you’ve come and what areas need more attention.

In short, the Sintelly app is a powerful tool for anyone dealing with panic disorder. With its CBT chatbot, exercises, and psychodiagnostic tests, it provides comprehensive support. You get immediate help during panic attacks, build resilience with regular exercises, and gain valuable insights into your mental health.