What are 5 characteristics of panic disorder?

Diagnosis

PD is defined by theDiagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V) as recurrent unexpected panic attacks followed by at least 1 month of anticipatory anxiety about having another attack, and a significant change in behavior to avoid another panic attack. A panic attack, the core feature of panic disorder, is an abrupt surge of intense fear/anxiety with concurrent physical and cognitive symptoms (Box 1). To be diagnosed as having PD, a patient must have more than one panic attack that is not the result of an obvious trigger or cue. The best example might be a nocturnal panic attack in which the individual is waking from sleep, with no external cues, in a state of intense fear (panic) and experiencing physical and cognitive symptoms. Expected panic attacks, that is, those for which there is an obvious cue or trigger, also occur in patients with PD. In the United States and Europe, approximately half of individuals with PD experience expected panic attacks as well as unexpected panic attacks. The presence of expected panic attacks does not rule out the diagnosis but is insufficient to make the diagnosis of this disorder.

A thorough diagnostic evaluation, including a complete history and thorough physical examination, is necessary to rule out medical or substance-induced panic attacks and establish the diagnosis of PD. Atypical symptoms or features of a panic attack may be suggestive of a medical illness or pharmacologic substance as the precipitant. A workup that includes laboratory tests such as complete blood cell count, complete chemistry panel (including calcium level), thyroid-stimulating hormone (TSH) level, and urine drug screen may be helpful in determining a medical or substance-related cause. These tests may be followed by a chest radiograph, an electrocardiogram, and cardiac enzymes, as warranted. If the clinical examination or history is suggestive, a Holter monitor, EEG, CT scan, or urine catecholamine assay may be performed.

Panic disorder (PD) is a relatively common anxiety disorder marked by recurrent, often unexpected panic attacks, which are typically described as surges of rapid-developing fear in a crescendo pattern. The nature of attacks in PD are heterogeneous, but are generally marked by palpitations, chest pain or pressure, dyspnea, and cognitive, neurological, or gastrointestinal symptoms. Besides the discrete attacks, marked anticipatory anxiety about having future attacks, behavioral avoidance of situations which might provoke attacks (such as bridges, elevators, enclosed spaces), and psychological concerns about ‘going crazy’ or ‘losing one’s mind’ are commonly observed. Lifetime prevalence estimates are 22.7% for panic attacks, 3.7% for PD without agoraphobia, and 1.1% for PD with agoraphobia. Herein, we review the clinical features of PD, the neurobiology of PD, and therapies presently available for PD.

Physical Findings & Clinical Presentation

Panic disorder:

Presents either with a panic attack or with fear and anxiety related to anticipation of a future panic attack or its implications.

Typical presentation: Unexpected, untriggered periods of intense anxiety and fear with associated physiologic changes (e.g., palpitations, sweating, tremulousness, shortness of breath, chest pain, gastrointestinal distress, faintness, derealization, paresthesia). This is accompanied by associated fear of dying, heart attack, stroke, passing out, losing control, or losing one’s mind. Panic attacks are often described as “the most terrifying” episode an individual has experienced.

Emergency or physician visits often occasioned by physical symptoms such as chest pain, palpitations, dizziness, or difficulty breathing. Thirty percent of patients presenting with chest pain have panic disorder.

In a recent study of 1327 patients reporting noncardiac chest pain, 77.1% had visited the emergency department following a panic attack.

Patients reporting a fear of dying from a panic attack tend to have more symptomatic panic attacks and agoraphobia.

Agoraphobia:

Rare complaints to physician. May manifest in missed office visits or tardiness. Patients may request home visits or telephone care.

Fear or anxiety about situations or activities such as the following:

Crowded public areas (stores, public transportation, flying, church)

Individual interactions (hairdresser, dentist, meetings)

Driving (especially if alone, far from home, over bridges, through tunnels, on highways, or on isolated roads)

This fear is a result of the belief that he or she might experience a panic attack and would be unable to exit readily. Patients may also experience fear of other symptoms, beyond the paniclike symptoms, such as falling or incontinence.

On exposure to or anticipation of exposure to feared situations, significant anxiety occurs. Anxiety may generate somatic symptoms that trigger a full- or limited-symptom panic attack. Patients believe that escape from these situations reduces the alarming symptoms, thus reinforcing future avoidance. In actuality, symptom relief stems from adrenaline breaking down in the body after approximately 20 minutes.

Clinical

Panic Disorder

Panic disorder consists of recurrent panic attacks. Although some panic attacks may be precipitated by situations known to be stressful, at least some attacks must be unexpected (“out of the blue”). Patients also exhibit anticipatory anxiety in which they experience ongoing psychic distress by worrying about their next panic attack or the attack’s effects (e.g., humiliation if the attack were to happen in public view). In addition, patients manifest avoidance behavior by staying away from known triggers or from situations in which having a panic attack might be dangerous (e.g., driving) or particularly distressing (e.g., in public spaces). For many patients, the anticipatory anxiety and avoidance behavior may be more disabling than the panic attacksthemselves. Avoidance behavior may overlap with agoraphobia, which is defined as a distressing and disabling fear of places or situations from which escape might be difficult or embarrassing or from which help might not be available in the event of panic-like symptoms. Common agoraphobic foci include being outside one’s home alone, being on bridges or in tunnels, traveling by vehicle, or being in crowds or lines. A third or more of patients with panic disorder have comorbid agoraphobia, whereas others have agoraphobia alone or comorbid with other conditions.

Panic disorder (PD) is a condition associated with recurrent, unexpected panic attacks, characterized by sudden surges of physical arousal symptoms and fear. PD occurs frequently in the general population and is often associated with other psychological problems, including other anxiety disorders, depression, and substance-use problems. PD appears to stem from an interaction of biological, psychological, and social factors. In the 1980s and 1990s, effective medications and psychological treatments were developed. In fact, brief treatment can lead to significant improvements for most people who suffer from this problem.

6.18.1 Panic Disorder and Agoraphobia Diagnosis and Phenomenology

Panic disorder is a psychological syndrome in which the individual has a fear of having panic attacks, which leads to excessive distress or avoidance.1 Panic attacks are sudden rushes of fear or discomfort that can be experienced as coming from out of the blue or no apparent reason (in DSM-5ת APA, 2013; and ICD-11, WHO, 2019; see Tables 1 and 2). At times, there are triggers such as behaviors (e.g., exercise), situations (e.g., being in a hot or crowded room, driving), or places (e.g., elevators, open spaces). When situational avoidance becomes significant, it is called agoraphobia (a distinct diagnosis in DSM-5 and ICD-11; see Tables 3 and 4). Panic disorder can lead to substantial distress and impairment (Craske et al., 2010). Panic attacks are comprised of at least 4 out of 13 symptoms occurring simultaneously (see Table 1). It should be noted that the frequency of panic attacks is not a sufficient indicator of severity of panic disorder, as some patients have found effective avoidance behaviors that minimize their panic attacks on a day to day basis, but typically at the cost of major lifestyle restrictions. Formal DSM criteria for panic disorder requires panic to reach its peak relatively quickly (e.g., within approximately 10 min), though some patients report either intense attacks over a longer period of time or multiple short attacks. DSM criteria for panic attacks formally require at least 4 of the 13 specific symptoms. However, culturally, some individuals may experience additional symptoms during a panic attack (e.g., neck pain, vomiting, crying). These symptoms should be taken into account, but are not included in the formal list of 4 required symptoms. As noted in Tables 2 and 4, ICD-11 criteria for panic disorder and agoraphobia are similar to DSM-5 criteria, but a bit less strictly defined.

Table 1. DSM-5 criteria for panic disorder

Table 2. ICD-11 criteria for panic disorder

Table 3. DSM 5 criteria for agoraphobia

1.

Severe fear or anxiety about 2 or more of the following 5 situations:

Public transportation (e.g., automobiles, buses, trains, ships, planes).

Open spaces (e.g., parking lots, marketplaces, bridges).

Enclosed places (e.g., shops, theaters, cinemas).

Standing in line

Being in a crowd.

Being away from home alone.

The individual fears or avoids these situations because of fears that escape will be difficult or help will not be available in the event of having a panic attack or other embarrassing symptoms (e.g., fear of incontinence; fear of falling).

The situations very frequently evoke fear or anxiety.

The situations are actively avoided, require accompaniment, or are endured with fear or anxiety.

The fear or anxiety is out of proportion compared with the actual danger that exists in the situations and the sociocultural context.

The fear, anxiety, and/or avoidance is persistent, typically lasting for 6 months or more.

The fear, anxiety, and/or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

If another medical condition (e.g., inflammatory bowel disease, heart disease) is present, the fear, anxiety, and/or avoidance is excessive.

The fear, anxiety, and/or avoidance is not better explained by another disorder—for example, symptoms are not only related to: specific phobia; include solely social situations (social anxiety disorder); and exclusive to obsessions (OCD); physical appearance (body dysmorphic disorder), reminders of trauma (posttraumatic stress disorder), or separation (separation anxiety disorder).

Note: Agoraphobia is diagnosed irrespective of the diagnosis of panic disorder. If the presentation meets criteria both for panic disorder and for agoraphobia, both diagnoses should be given.

Table 4. ICD-11 criteria for agoraphobia

Agoraphobia is characterized by marked and excessive fear or anxiety that occurs in response to multiple situations where escape might be difficult or help might not be available such as using public transportation being in crowds being outside the home alone (e.g., in shops theaters standing in line). The individual is consistently anxious about these situations due to a fear of specific negative outcomes (e.g., panic attacks other incapacitating or embarrassing physical symptoms). The situations are actively avoided entered only under specific circumstances such as in the presence of a trusted companion or endured with intense fear or anxiety. The symptoms persist for least several months and are sufficiently severe to result in significant distress or significant impairment in personal family social educational occupational or other important areas of functioning.

A controversial issue is the differentiation of panic disorder from agoraphobia. Historically, from DSM III (1980) through DSM IV-TR (2000), there were two diagnoses of panic disorder—one with and one without agoraphobia—and there was a separate diagnosis of agoraphobia without panic (see Asmunsdon et al., 2014; Wittchen et al., 2010). DSM-5 made a number of changes to the panic disorder and agoraphobia diagnoses from DSM-IV, and also made “with panic attacks” a potential descriptor for any DSM diagnosis. Agoraphobia (“fear of the marketplace” in Greek; connotation of a fear of either leaving the house or being in open spaces) was one of the earliest diagnoses to be described. It was first coined by Westphal in 1871 (Wittchen et al., 2010). Agoraphobia became a diagnosis related to “marked and excessive fear or anxiety that occurs in or in anticipation of multiple situations where escape would be difficult or help not available” (Reed et al., 2019, p. 12). This definition became more and more related to fear of panic or panic-like sensations in each iteration of DSM, until a break was made with the advent of DSM-5. Notably, the definition of agoraphobia in the ICD never necessitated panic attacks or panic-like sensations in agoraphobia. Thus, one goal of the change in the DSM-5 was to make the diagnosis of agoraphobia more in line with the ICD definitions.

To elaborate, the controversy that exists is that (1) on one hand both clinical research data and clinical experience suggest that most individuals who seek treatment for agoraphobia tend to have panic attacks and/or panic disorder, and (2) there are individuals who engage in substantial, impairing agoraphobic avoidance who do not have panic or panic-like experiences. The tensions that exist between these two notions are somewhat disputed (Wittchen et al., 2010). Those who advocate a distinct diagnosis of agoraphobia from panic disorder argue that it is improper to give panic disorder unconditional priority over agoraphobia. In contrast, those who advocate for a diagnosis of panic disorder with agoraphobia argue that when the two are present, it is redundant to diagnose two distinct disorders, particularly when one of the goals of the diagnostic system is to be as parsimonious as possible. The elimination of the hierarchical panic disorder with agoraphobia diagnosis leads to an inflated comorbidity rate for panic disorder and agoraphobia. Nevertheless, the argument for the distinction of the two diagnoses has existed in ICD, including in the most recent version (ICD 11; Reed et al., 2019). ICD has also worked on honing the definition of agoraphobia, stating that the focus of apprehension is fear of specific negative outcomes that would be incapacitating or embarrassing, which is broader than the narrower definition in previous versions of ICD where the focus was on fears of open spaces or related situations such as crowds where escape would be difficult. One reason for expanding this criterion was to make the diagnosis more applicable to low and middle income countries (Kogan et al., 2016). Notably, agoraphobia typically requires anticipatory anxiety or avoidance of two or more situations, and its precedence over panic disorder was eliminated in ICD 11. An addition of “with panic attacks” also became a general descriptor that could be used for all disorders, including agoraphobia. This is in line with attempting to bring DSM and ICD criteria together and an effort to create uniform criteria.

When considering treatment of panic disorder, one of the first essential steps is establishing the diagnosis and also ruling out differential diagnoses. It is important to consider that many individuals have panic attacks (estimates of at least 20%; Wittchen et al., 2010), but only approximately 1% of individuals (or 3%–5% of those who have had panic attacks) have panic disorder (see next section for more information). Indeed, both DSM-5 and ICD-11 include a diagnostic specifier of “with panic attacks” for other disorders aside from panic disorder itself (i.e., there is no diagnosis of panic disorder with panic attacks); however, the specifier can apply to agoraphobia (i.e., agoraphobia with panic attacks). The apparent differentiation is that agoraphobia with panic attacks would be diagnosed if panic attacks have always been triggered solely in agoraphobic situations and presumably only when the onset of agoraphobia preceded the panic attacks. Important differential diagnoses include other anxiety disorders, in which panic attacks are cued by the feared situations (e.g., enclosed spaces in claustrophobia, social situations in social anxiety disorder). Additionally, similar related disorders which can trigger panic attacks range from posttraumatic stress disorder (PTSD), to obsessive compulsive disorder (OCD), to more distinct disorders such as schizophrenia or borderline personality disorder.

Clinical Features

The first panic attack typically occurs in young adulthood. Although there is no identifiable immediate precipitant, often the attacks follow a recent period of emotional or physical stress. The symptoms begin suddenly and escalate in intensity over a period of a few minutes. The attack may last from approximately 20 min to several hours. Most patients immediately experience a sense of escalating panic and are bewildered as to why they should be feeling so frightened but are unable to suppress the symptoms. Patients often describe a desperate fear of impending disaster, serious medical illness or death, or of “going crazy.” Associated somatic symptoms include palpitations, hyperventilation and shortness of breath, sweating, trembling, extreme restlessness, tightness or pain in the chest, dizziness, and numbness or tingling in the face or extremities. The attack usually tapers off gradually or may sometimes end abruptly. Many patients rush to emergency rooms with the belief that they are having a heart attack. Between attacks, patients may develop a degree of anticipatory anxiety due to fear of having another panic attack.

Those patients who develop agoraphobia begin to avoid situations that they associate with precipitating the panic attack or from which it would be difficult to escape or obtain help. Sometimes, they insist on being accompanied by a friend or relative when leaving the house; others become so severely incapacitated that they find it difficult to leave home at all, even accompanied.

Symptoms of depression are frequently present in panic disorder, often sufficient to merit a comorbid diagnosis of major depressive disorder. Phobias, obsessive–compulsive disorder, and substance abuse also occur more frequently in individuals with panic disorder than in the general population.

Mediating Autonomic Mechanisms of Cardiac Risk During a Panic Attack

Our own extensive clinical experience with the cardiological management of panic disorder sufferers has provided case material encompassing the range of cardiac complications which occur. Those patients with typical, severe anginal chest pain during panic attacks, who are in the minority, appear to be at cardiac risk. During panic attacks in such patients we have documented, variously, triggered cardiac arrhythmias, recurrent emergency room attendances with angina and ECG changes of ischemia, coronary artery spasm during panic attacks occurring at the time of coronary angiography (Fig. 126.4) and myocardial infarction associated with coronary spasm and thrombosis. Our research findings suggest that release of epinephrine as a cotransmitter from cardiac sympathetic nerves and activation of the sympathetic nervous system during panic attacks may be mediating mechanisms.

In this context, release of neuropeptide Y from the sympathetic nerves of the heart into the coronary sinus during the sympathetic activation accompanying panic attacks is an intriguing finding, given the capacity of NPY to cause coronary artery spasm [10]. A better understanding of the mechanism of coronary artery spasm in panic disorder would facilitate therapeutic intervention. At present we treat patients with panic disorder and clinical evidence of coronary spasm with drugs and other measures aimed at preventing or minimizing their panic attacks, a dihydropyridine calcium-channel blocker as a non-specific anti-spasm measure, and low-dose aspirin as prophylaxis against coronary thrombosis during spasm [5]. Neuropeptide Y antagonists are not yet available for clinical use.

Abstract

Panic disorder (PD) is an anxiety disorder associated with the occurrence of panic attacks, which arise suddenly without warning. Panic disorder represents a serious psychiatric condition and it can induce complications related to the fear of having subsequent panic attacks and avoidance behaviors. Given its importance, many studies have been conducted to elucidate the circuitry involved in this disorder. Clinical and preclinical studies suggest that PD can be modulated by a specific network of brain structures controlling emotional behaviors and autonomic responses. Using animal models that allow measurement of responses related to behavioral and autonomic symptoms of panic attacks in humans, it has been shown that the neuromodulator serotonin plays an inhibitory role in control of panic attacks associated with PD. Understanding the pathways through which serotonergic systems modulate panic-like responses is key to understanding the biological basis of panic attacks and PD, and, consequently, to establishing novel therapeutic strategies for treatment of PD.