American Board of Psychological Specialties

Panic attacks are reactions to extreme stress or anxiety and are not uncommon. In fact, 9% to 14% of the population has experienced a panic attack (Kleinknecht, 1991). The presence of panic attacks alone is not necessarily indicative of panic disorder. As noted by Barlow and Durand (2005), there are three distinct types of panic attacks. Situationally bound or cued panic attacks occur only when people affected are exposed to specific situations, whereas unexpected or uncued panic attacks are not isolated to specific settings and occur randomly. And, in situationally predisposed panic attacks, certain settings increase the likelihood of an attack, but not always will an attack occur in those settings. Situationally-cued panic attacks are typically related to specific phobia, another anxiety disorder. However, when panic attacks randomly occur on a regular basis they can be symptomatic of a larger problem, panic disorder. The American Psychiatric Association (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) defines a panic attack. “. . . A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes: Palpitations, pounding heart, or accelerated heart rate Sweating Trembling or shaking Sensations of shortness of breath or smothering Feeling of choking Chest pain or discomfort Nausea or abdominal distress Feeling dizzy, unsteady, lightheaded, or faint Derealization (feelings of unreality) or depersonalization (being detached from oneself Fear of losing control or going crazy Fear of dying Parathesis (numbness or tingling sensations) Chills or hot flashes (Diagnostic and Statistical Manual of Mental Disorders, 2000) Characteristics Panic disorder is an anxiety disorder in which an individual has panic attacks on a regular, yet seemingly unexplainable basis (Bouton, Mineka, & Barlow, 2001). There are between 3 and 6 million Americans suffering from panic disorder (Beamish, Belcastro, & Granello, 2002). Panic disorder is most likely to occur in individuals between their mid-teens and 40 years of age (Bouton et al.). As noted by Barlow and Durand (2005), there is high comorbidity of panic disorder with other anxiety and depressive disorders. As many as 55% of those with panic disorders also have one or more anxiety,  or depressive disorders. This high comorbidity rate can often affect intervention, which will be discussed later. To be diagnosed with panic disorder, patients must worry persistently about having another attack, worry that the attack is symptomatic of a larger problem, or make some noteworthy change in their behavior, such as avoiding certain people or places. This worry must be present for at least 1 month. The attacks cannot be connected with any drug use, licit or illicit, nor can they be due to any other medical condition. Patients should not be diagnosed with panic disorder if their panic attacks can be correlated with specific stressors. If this is the case, then another mental disorder would most likely be a better fit (APA, 2000). An important issue associated with panic disorder is agoraphobia. Agoraphobia is severe fear or anxiety related to a place or situation from which escape may be difficult (APA, 2000). Often this anxiety is so severe that sufferers will rarely leave the house in an effort to avoid a panic attack (Bouton et al., 2001). This avoidance can be seen as a coping mechanism to help deal with their anxiety. Individuals suffering from panic disorder without agoraphobia tend to cope in other ways, such as drug or alcohol abuse (Bouton et al.). Because so many individuals with panic disorder also have agoraphobia, the American Psychiatric Association has given panic disorder with agoraphobia a diagnostic code separate from panic disorder without agoraphobia. The focus of this paper is panic disorder without agoraphobia.

Etiology

There are several theories regarding the causes of panic disorder, none of which appear to fully explain why it occurs (Jacobs & Nadel, 1999). Some think there is a purely biological explanation, while others posit that panic disorder is a learned behavioral response to stressful situations (Barlow, Brown, & Craske, 1994; Jacobs & Nadel). A third perspective suggests that initial panic attacks are based on the body’s natural fear reaction occurring at an inappropriate time. Following this initial attack a small percentage of individuals develop anxiety based on fear of further attacks (Barlow et al.). As no one theory fully explains panic disorder, it is necessary to examine several theories to better understand panic disorder.

Genetic and Biologic Theories It appears there is at least a moderate case for the heritability of panic disorder. Studies have shown as many as 30% of immediate (first degree) family members share panic disorder (Zal, 1990). However, these data are complicated by shared environment and the opportunity for “vicarious learning” (Bouton et al., 2001). Even with these complicating factors, Kendler, Neale, Kessler, Heath, and Eaves (1992), as reported in Bouton et al., indicated that genetic factors were responsible for 35% to 39% of panic disorder and agoraphobia cases among female twins. Studies also identify specific chemical sensitivities to explain the occurrence of panic disorder. Certain substances can be used to trigger panic in individuals who are vulnerable to their effects (McNally, 1990). Substances that have been used to induce panic include sodium lactate, norepinephrine, isoproterenol, yohimbine, caffeine (McNally), and a mixture of carbon dioxide and oxygen (Lejuez, Eifert, Zvolensky, & Richards, 2000; McNally). Researchers who support this theory think that because of the subjects’ heightened sensitivity to these panic-inducing substances they are biologically predisposed to panic attacks. Critics point to data suggesting that patients with a history of panic attacks do not have any stronger physiological reactions to these stimuli than normal individuals, they simply respond more fearfully to those stimuli. This would suggest a psychological, not biological cause (McNally).

Psychological Theories One psychological approach to the etiology of panic disorder is cognitive theory. According to cognitive theory, individuals who suffer from panic disorder build their own fear and anxiety through negative thought patterns by focusing on physiological feelings and ascribing their own meaning to them (Bouton et al., 2001). An example of this would be a person who is a little short of breath and readily takes this as evidence that he or she is suffocating. Whether there is a real problem or not, the thoughts create their own anxiety. This anxiety becomes evidence that something really is wrong, which leads to more negative thoughts. This process continues until a panic attack occurs. Support for this theory has been built through clinical experiments in which negative word pairs are read to a subject with the intent of eliciting a panic-like response (Bouton et al.). Problems inherent with cognitive theory are that it does not address the development of the panic reaction, or account for panic attacks that occur in the absence of negative cognition (Bouton et al., 2001; Jacobs & Nadel, 1999). Another theory closely related to cognitive theory is anxiety sensitivity (Bouton et al., 2001). As with cognitive theory, anxiety sensitivity theory hypothesizes that individuals suffer from negative thoughts that can exacerbate their anxiety. With anxiety sensitivity theory, however, the person’s focus is on long-term problems associated with the attacks. They believe that they are doing harm to their overall mental or physical state. For example, cognitive theorists would say that clients are afraid they are having a heart attack, while an anxiety sensitivity theorist would say that clients are fearful that the panic attacks are slowly but surely damaging their heart (Bouton et al.). Anxiety sensitivity theory, like cognitive theory, fails to address the problems of how the panic attacks developed and how they exist in the absence of negative thoughts. A psychological theory that does address the development of the panic reaction is conditioning theory. Conditioning theory suggests that when a stimulus is paired with the physical symptoms of a panic attack, that stimulus is conditioned to elicit the same physiological response the next time it is encountered (Bouton et al., 2001). An example of this would be fear of mice. If a person’s first experience with a mouse elicits strong physiological symptoms, then that person is more likely to experience those same feelings when encountering a mouse again, thereby strengthening the response each time a mouse is encountered. Criticisms of conditioning theory are numerous. One important issue worth discussing is that the anxious reaction (the elicited response) is conditioned by anxiety (Bouton et al.; McNally, 1990). This concept does not appear to have much face validity, as it states that anxiety makes itself stronger. This and other issues have raised much speculation about the usefulness of conditioning theory.

Psychosocial Considerations Race and ethnicity appear to have no direct relationship to panic disorder. However, gender is strongly correlated with panic disorder. Women are two-and-a-half times more likely than men to receive a diagnosis of panic disorder. This gender gap also increases with age (Sheikh, Leskin, & Klein). Women were also found to have more and severer symptoms of panic disorder with agoraphobia than men (Sheikh et al.). Seventy- five percent of all individuals having panic disorder with agoraphobia are female (McNally, 1990). No theories have adequately explained this gender gap; however, according to Herman and Deitch (1986), it has been shown to be steady “across geographic, cultural, and socioeconomic boundaries” (as quoted in Zal, 1990, p. 102). Panic disorder can be triggered by stressful situations. This could include losing one’s job, marital difficulties, substance abuse issues, depression, loss of a loved one, or any other situation that causes excessive amounts of stress for an individual. Between 75% and 91% of patients being seen for panic-related problems had experienced a recent major life stressor (Kleinknecht, 1991). This leads one to believe that the single-most important psychosocial predictor of panic disorder is the perceived stress level of one’s environment.

Summary Panic disorder, with or without agoraphobia, can be debilitating. Most common among women, it leaves the sufferer constantly in fear of another attack and powerless to stop the attack once it has begun. Panic disorder is caused by many complex and unclear interrelated issues, including biology, genetics, behavioral conditioning, cognitive errors, and psychosocial stressors. Hopefully, with continued research and experimentation, we will gain a clearer picture of this devastating disorder. Panic disorder is a pervasive problem affecting 3 to 6 million Americans at any given time (Beamish et al., 2002). Panic disorder is characterized by the occurrence of panic attacks on a regular, seemingly unpredictable basis (Bouton et al., 2001). Often those who suffer from panic disorder turn to drugs or alcohol to help alleviate some of the associated anxiety. Others who suffer from panic disorder with agoraphobia rarely leave the house in an effort to avoid the onset of a panic attack (Bouton et al.). With panic disorder affecting the lives of so many, effective treatment becomes extremely important. For many individuals, successful treatment could mean the difference between a fulfilling, satisfying life and a life filled with constant anxiety, substance abuse, and/or social isolation.

Treatment Approaches: Strengths and Limitations Research on the efficacy of treatment of panic disorder has been hampered by many methodological concerns. As noted by Addis et al. (2004), poorly defined samples render between-study comparisons virtually impossible. Much of the difficulty can be attributed to the high comorbidity of panic disorder with other anxiety and depressive disorders. Also, treatment methods may be poorly defined, reducing the likelihood of replication by subsequent researchers. Nevertheless, some tentative findings have improved understanding of panic disorder. Approaches to the treatment of panic disorder can be separated into three broad categories; pharmacological, psychological (Beamish et al., 2002; Barlow & Durand, 2005; Craske, 1999); and combined approaches (Spiegel & Bruce, 1997).

Pharmacological Approach The pharmacological approach is based on the assumption that there is a biological cause to panic disorder (Beamish et al., 2002). This approach focuses on the use of either benzodiazepines or anti-depressants, including SSRI’s and tricyclics, to control the body’s responses to internal, exaggerated panic cues (Beamish et al.; Craske, 1999). Both drug categories have their advantages and disadvantages. Benzodiazepines are frequently prescribed because they have been shown to quickly and effectively alleviate the symptoms of panic attacks (Beamish et al.; Barlow & Durand, 2005). The most attractive quality of benzodiazepines is the speed with which they work, having no need to build in the system (Beamish et al.; Barlow & Durand). The most frequently prescribed benzodiazepines are Xanax (alprazolam) and Klonopin (clonazepam), due to their high potency (Beamish et al.). Major side effects that can occur with the use of benzodiazepines include sedation and problems with motor skills or coordination. It is also important to note that benzodiazepines are addictive and may be difficult to stop taking because of psychological dependence and physical withdrawal (Beamish et al., 2002; Barlow & Durand, 2005). Another important group of drugs used to treat panic disorder is anti-depressants. There are two categories of anti-depressants used in the treatment of panic disorder, serotonin specific reuptake inhibitors (SSRI’s) and tricyclics (Beamish et al., 2002). A third group, monoamine oxidase inhibitors (MAOI’s), is used infrequently today because of extreme side effects and drug interactions (Beamish et al., 2002). SSRI’s (Prozac & Paxil) have become the more popular option among the anti-depressants in recent years (Barlow & Durand, 2005; Craske, 1999). This is because of an extremely low risk of overdose, and a reduced level of side effects compared with other options (Beamish et al., 2002). Side effects from SSRI’s are even less of an issue when they are used in treating panic disorder, because the drug is effective at much lower doses than when used to treat other disorders (Beamish et al.). The major side effect associated with SSRI’s is sexual dysfunction, which is experienced by as many as 75% of all users (Barlow & Durand). Tricyclics are the second most popular group of anti-depressants used to treat panic disorder; however, results are mixed and side effects can be many (Beamish et al., 2002; Barlow & Durand, 2005). Among the tricyclics, only imipramine (Tofranil) and clomipramine (Anafril) have been proved to be truly beneficial, while others such as desipramine (Norpramin), notriptlyine (Pamelor), and amitriptyline (Elavil) have not been thoroughly tested, and still others, specifically matprotiline (Ludiomil) and amoxapine (Asendin), have been shown to be ineffective (Beamish et al.). Another drawback to tricyclics is that they take as long as 8 weeks to reach an effective therapeutic level (Beamish et al.). Side effects of tricyclics can include dry mouth, constipation, blurred vision, memory difficulties, weight gain, drowsiness, inhibition of sexual functioning, light-headedness, and skin rash. Tricyclics also carry a risk of overdose. Given that as many as 20% of patients suffering from panic disorder attempt suicide, this can be a serious risk (Beamish et al.). Pharmacological treatment of panic disorder is an important and complex treatment issue. Advantages of pharmacological treatment include rapid symptom reduction and a variety of treatment options (Spiegel & Bruce, 1997). In addition, medications used to treat panic disorder are common and widely available. Those with limited access to other treatment options could benefit from medical intervention in the absence of other treatment options. Despite these advantages, there are some concerns with pharmacological interventions and panic disorder. For example, SSRI’s have been shown to have sexual side effects for as many as 75% of all patients, and Benzodiazepines can have powerful sedative and addictive qualities (Barlow & Durand, 2005). As suggested by Otto, Pollack, and Maki (2000), when medications are discontinued, most people see symptoms return. Some have argued that medication reduces the likelihood that patients will learn skills to cope with panic without medication, thereby rendering them dependent upon medication (Spiegel & Bruce, 1997). Thus, medication may produce short-term gains, but long-term gains with medication are questionable. As such, pharmacological treatments are expensive because removal of medication typically leads to symptom resurgence (Otto et al.). When addressing medication, it is always necessary to weigh the positive outcomes of the treatment against the potentially harmful effects of medication.

Cognitive-Behavioral Treatment Studies show Cognitive-behavioral theory is an extremely effective treatment for panic disorder, with as many as 70% of all patients showing considerable reduction of panic and anxiety (Barlow & Durand, 2005). Cognitive-behavioral treatment is based on the premise that people suffering from panic disorder cognitively misinterpret normal physiological responses, such as a rapid heartbeat or heavy breathing, as signs that something dangerous is happening; thereby activating their fight or flight response and causing them to panic (Beamish et al., 2002). Through the use of cognitive-behavioral treatments, therapists attempt to alter clients’ perceptions of their bodies’ physiological responses (Beamish et al.). As suggested by Smits, Powers, Cho, and Telch (2004), reduction in the fear-offear response (the overreaction to benign bodily sensations) is a necessary component in cognitive treatment of panic disorder. Cognitive-behavioral therapy for panic disorder typically encompasses four basic areas—panic education, cognitive restructuring, respiratory control, and exposure (Addis et al., 2004; Beamish et al., 2002 Craske, 1999). Panic education involves educating the client on the differences between what they think and what they feel (Beamish et al.; Craske). By giving a physiological explanation for where the body’s panic response is originating, the client should understand that these are normal body functions, not catastrophic events (Craske, 1999; Beamish et al., 2002). After panic education takes place, cognitive restructuring can begin. Cognitive restructuring involves changing the way clients think about the things that feed into their panic response (Beamish et al., 2002; Craske). An example of this might be a client who thinks he or she is having an asthma attack because his or her heart rate is a little fast. Clients are taught to question their interpretations of the way they feel and gather evidence that supports a more realistic picture of the things they fear (Addis et al., 2004; Beamish et al., 2002; Craske). These skills must be built so that they can carry into the final stages of therapy and beyond (Craske). The next stage in cognitive-behavioral therapy is respiratory control, or breathing retraining (Beamish et al., 2002; Craske). This stage focuses on explaining the physiology of hyperventilation and teaching proper breathing techniques. These techniques can be used all the time, and are thought to be helpful in times of anxiety or panic (Craske). By learning appropriate breathing methods the client is helping eliminate one of the biggest body cues that can lead to a panic attack. However, controlled breathing has received criticism (Schmidt et al., 2000). Some have argued that controlled breathing is a “false safety aid.” As noted by Schmidt et al., false safety aids may actually maintain panic reaction by preventing (or distracting) the person from experiencing anxiety and thereby learning skills to cope with anxiety. They further suggest that successfully coping with anxiety is a superior skill when compared to distraction techniques, of which controlled breathing is considered. Nevertheless, some research indicates that controlled breathing can be useful for some who experience panic attacks. Additional research is needed to determine who benefits and who does not benefit from controlled breathing training. After respiratory control, the client will work on exposure to feared stimuli or feared body responses (Beamish et al., 2002; Craske). Barlow and Durand (2005) refer to this as panic control treatment. In a controlled situation, clients will attempt to induce a panic response by hyperventilating, or elevating their heart rate, or by using any of the other physiological cues that have led to panic attacks in the past (Barlow & Durand; Craske). By allowing these panic sensations to occur, but not reacting to them, the client is, in effect, breaking the link between the stimulus and the panic response (Barlow & Durand; Beamish et al.; Craske). Cognitive-behavioral treatment can be used in either an individual or a small group approach; however, it is important that all members of a group are given large amounts of individual attention. Craske (1999) recommends individual treatment or, at most, groups of three to five with an extra therapist present and extra time allotted. Treatment should also be intensive, with two sessions a week to begin with and one session a week later in the treatment process (Craske). Despite the apparent high success rate of cognitive behavioral treatment and panic disorders, there are some areas of concern. As noted by Spiegel and Bruce (1997), cognitive behavioral approaches may take longer to achieve tangible results than pharmacological treatments. Also, treatment compliance can be problematic for those receiving cognitive behavioral treatment for panic disorder. Schmidt and Woolaway- Bickel (2000) noted that most cognitive behavioral interventions rely heavily on homework assignments and/or practice exercises apart from actual treatment sessions. Clients who fail to complete homework may not succeed in treatment. Client motivation becomes a variable in treatment success. While cognitive behavioral treatment creates long-term gains, initially it may be more taxing on clients and require more time to produce tangible results for clients than pharmacological interventions.

Combined Approaches As the name implies, combined approaches use cognitive behavioral treatment in conjunction with pharmacological treatment (Otto et al., 2000). Several advantages for treatment of panic disorder with combined approaches have been noted. For those with severe symptoms resulting in debilitation, starting with medications can be helpful in providing immediate symptom reduction. This may also be true for those with comorbid depressive and anxiety disorders. Once the client is stabilized with medication, cognitive behavioral treatment can be introduced to teach coping skills. The intention of the added cognitive behavioral treatment would be to facilitate tapering of pharmacological treatment (Siegel & Bruce, 1997). As clients acquire skills, medication can be accordingly adjusted until it can be discontinued. As previously noted, cognitive behavioral treatment requires active participation by clients. For those severely affected by panic disorder, medication can be used to increase active participation in cognitive behavioral treatments. Similarly, those who start with cognitive behavior treatment and have little success, pharmacological intervention can improve efficacy of cognitive behavioral treatment. This is especially true with the exposure component of cognitive behavioral treatment. When clients are exposed to panic-producing stimuli, they may have a strong, adverse reaction causing them to leave treatment prematurely. The use of medication during the initial stages of exposure therapy may be effective in reducing anxiety associated with exposure to panicproducing stimuli. Opponents of combined approaches (Spiegel & Bruce, 1997) suggest that medications can interfere with cognitive learning. Depending on the medications used, clients may have difficulty retaining cognitive content. Furthermore, motivation to learn coping skills can be compromised. Because medication yields desired symptom reduction with very little effort from clients some may be content with taking medication rather than learning to cope without medications. Though these are compelling arguments, combined methods have been useful long term treatment of panic disorders. Additional research is needed to evaluate the overall efficacy of combined treatments.

Treatment Selection: Clinical Considerations Given the array of treatments available, selection of the appropriate treatment or treatments for panic disorder can be complex. Several factors influence treatment selection. These include comorbidity with other disorders, frequency and intensity of panic attacks, client motivation for treatment, treatment availability, client preference, client characteristics, and cost. As noted earlier, the presence or absence of comorbid conditions with an identified panic disorder can influence treatment selection and outcome of treatment. Thorough initial assessment of clients before the start of treatment may facilitate identification and treatment of panic disorder and comorbid conditions, if present (Barlow & Durand, 2005). Failure to identify and treat comorbid conditions can adversely affect treatment outcomes. For those with severe, frequently occurring, and debilitating panic symptoms, it may be necessary to begin with pharmacological intervention (Spiegel & Bruce, 1997). The goal would be to stabilize initial symptoms and prepare clients for skill acquisition, thereby eliminating the need for medication. Those with mild to moderate, infrequent panic attacks may respond to cognitive behavioral treatment because they recognize their symptoms are manageable without medications. Mild and moderate panic-attack clients may also have greater motivation and are more readily able to complete homework and other activities compared to those with severe panic attacks. Client motivation is a key factor in treatment methods that require active client participation. Clients with low motivation may easily accept pharmacological treatment because it is more passive and requires less client-generated activity than cognitive behavioral treatment (Schmidt & Woolaway-Bickel, 2000). Treatment availability is also a contributing factor in treatment selection. Those with few options may be forced to use the treatment available regardless of personal preference. In some areas, there may be few clinicians with cognitive behavioral training sufficient to treat moderate and severe panic disorder (Barlow & Durand, 2005). In such instances, pharmacological treatment may become the default treatment. It has been noted by some (Otto et al., 2000), that pharmacological treatments are more costly than cognitive behavior treatments. Clients with limited resources may opt for cognitive behavioral treatment because it is time-limited (12 sessions or less) and produces long-term results with less relapse than pharmacological treatments. Despite cost-effectiveness associated with cognitive behavioral approaches, those with severe symptoms and debilitation may require pharmacological treatment. Unfortunately, those with few personal resources may be excluded from cost-prohibitive pharmacological treatments. Client characteristics can influence client preface of treatment (Otto et al., 2000). Most ethnic and cultural groups seem to experience panic disorder equally; however, they do not experience the same symptoms of panic, or at least do not describe them in the same manner (Barlow & Durand, 2005). Therefore, it is important for therapists to treat panic disorder on an individualized basis. Treatment plans must be tailored to the client’s specific needs and preferences (Barlow & Durand, 2005; Beamish et al., 2002; Craske, 1999). Educating clients on the array of treatments available, the strengths and limitations of treatment options, and the overall effectiveness of treatment approaches increases active participation in the treatment process. Client comfort with treatment options can positively impact client involvement and motivation.

Conclusion Panic disorder is a problem that transcends socioeconomic status, gender, and many other characteristics. It can be debilitating for all those who suffer from it, leaving them constantly with the fear that another panic attack may occur at any moment. Fortunately, there are effective treatments for this disorder. Cognitive behavioral interventions have been demonstrated as the most effective long-term treatment for panic disorder, while pharmacological treatments have proved effective in rapid symptom reduction of panic disorders. Combined approaches may be used when there is comorbid anxiety or depressive disorders and/or the frequency of panic attacks create debilitation for those afflicted. The key is selecting the right intervention for the right client for the right reasons. Through medication, cognitive-behavioral therapy, or a combination of the two, many of those who suffer with panic disorders can lead happier, more meaningful lives.

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About the authors James L. Whalen is a graduate student in the School of Social Work at Western Michigan University. He is a graduate assistant for the field instruction office.

Robin E. McKinney is an assistant professor of Social Work at Western Michigan University and a clinician at Catholic Family Services in Bay City Michigan Dr. McKinney has written many mental health-related articles. He is a Licensed Social Worker and Licensed Professional Counselor in Michigan. He is also a Diplomate of the American Psychotherapy Association of which he has been a member for 3 years.