Panic Disorder

Introduction
Panic Disorder is defined by the DSM 5 “as recurring, unexpected panic attacks characterized by an abrupt surge of intense fear or discomfort that reaches a peak within minutes.” There are subsequently fears regarding the attack such as preoccupation with additional attacks and worry about the possible meaning or consequences of the attacks. Often, but not always, panic can lead to “agoraphobic” avoidance of situations, activities or reliance on what is commonly referred to as safety-seeking behaviors.
Panic Disorder is also accompanied by four or more of the following symptoms:
  • Palpitations
  • Fear of losing control or going crazy
  • Feeling dizzy, unsteady, lightheaded or faint
  • Trembling or shaking
  • Sweating
  • Shortness of breath or smothering sensations
  • Chest pain or discomfort
  • Derealization ( feeling that things are unreal) or depersonalization (feeling of being disconnected or detached form yourself
  • Chills or hot flushes
  • Fear of dying
  • Parestheisas (numbness or tingling sensation)
  • Nausea or abdominal discomfort
  • Fear of choking or a sensation of choking
Agoraphobia is defined as anxiety about places, situations or even activities where escape might be difficult or where help might not be available if a panic attack were to occur. Agoraphobia usually develops as a result of panic disorder. People with agoraphobia often avoid a broad range of situations such as large indoor or outdoor places or venues, being alone, doing something alone outside of the home, crowds, bridges, elevators and/or traveling by car, plane, train or airplane. Agoraphobic avoidance is self-reinforcing, often begets avoidance and consequently can spread across many areas of a person's life. Untreated this can lead to serious limitations and disability. Panic can occur alone but often progresses to agoraphobic avoidance as situations and activities become associated with the panic attacks ( associative learning ).

Epidemiology
The estimated lifetime prevalence of panic in the general population is between 1.5 and 3.5 %. Women are twice as likely to experience panic than are men; although the clinical feature of the disorder are similar across the genders.

Treatment
Cognitive and behavioral treatment is most commonly used. David Barlow’s model of panic is still the gold standard today. Barlow’s pioneering model based on extensive research identified key features of panic such as associative learning, biology of species survival and misinterpretation of this physiology. The approach he and colleague Michelle Craske developed, Panic Control Therapy, is still the considered the first line treatment for panic.

Treatment Components in Panic Control Therapy (PCT)
The essential goals in PCT include:
  1. controlling physical sensations
  2. changing self talk as well as understanding core beliefs behind fears
  3. facing more comfortably what is feared and avoided
Below is a summary of common PCT components:
  • Initial assessment
  • Education about the nature and physiology of anxiety and panic
  • Monitoring of panic symptoms
  • Defining the panic symptom profile
  • Defining specific triggers
  • Mapping of avoidance and safety-seeking behaviors
  • Ongoing monitoring of tasks and symptoms
  • Self-soothing techniques such as breathing control strategies and relaxation training
  • Cognitive strategies and interventions (challenging and reframing catastrophic misinterpretations of body sensations, decastrophizing fears)
  • Identifying core beliefs or vulnerable self narratives present in catastrophic interpretations
  • Exposure and desensitization to feared body sensations
  • Symptom induction exposure (“interoceptive exposure”)
  • Progressive situational exposure to avoided activities and places, reversing agoraphobic avoidance
  • Relapse prevention strategies and maintenance goals
  • Stress management strategies
  • Recovery and resetting of life goals.