Panic Attacks and Panic Disorder

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Chapter
Panic Attacks and Panic Disorder
DimitarBonevski and AndromahiNaumovska
Abstract
A panic attack is an intense wave of fear characterized by its unexpectedness
and debilitating, immobilizing intensity. Regardless of the cause, panic attacks are
treatable. The signs and symptoms of a panic attack develop abruptly and usually
reach their peak within 10min. Panic attack symptoms may include hyperventila-
tion, heart racing, chest pain, and trembling, sweating, and dizziness, with a fear
of losing control, going crazy, or dying. Although the exact causes of panic attacks
and panic disorder are unclear, the tendency to have panic attacks runs in fami-
lies. There also appears to be a connection with major life transitions and severe
stress. Treatment for panic attacks and panic disorder include psychotherapy and
medication.
Keywords: panic attacks, panic disorder, symptoms, causes, treatment
. Introduction
A panic attack is an intensive fear characterized by unexpectedness and immobi-
lizing intensity. Often strikes without any warning, very often with no clear trigger,
and also may occur when the person is relaxed or even when is asleep. Panic attacks
are common. A panic attack can be a one-time occurrence, but usually many people
experience repeat episodes, in a longer lifetime period. Among persons that ever
had a PA, the majority had recurrent PAs (66.5, s.e. 0.5%). Most people recover
without treatment, only a few of them from panic attacks develop panic disorder.
Lifetime prevalence of PAs is 13.2% (s.e. 0.1%) [18].
Sometimes recurrent panic attacks are often triggered by a specific situation, in
which the person felt endangered before. A panic attack may also occur as part of
another disorder, such as panic disorder, social phobia, or depression.
Depending on the relationship between the occurrence of the attack and absence
or presence of situational triggers, panic attacks can be divided into the following:
• Unexpected (untested) panic attacks in which the occurrence of a panic attack
is not related to a situation trigger (occurs spontaneously as a lightning strike)
and is the most common type of attack in the PD [44].
• Situational-induced (triggered) panic attacks, which almost invariably occur
immediately after exposure, or the anticipation of a trigger situation (e.g.,
seeing a snake or dog always triggers an immediate panic attack).
• Situational predisposed panic attacks, which is highly expected to occur when
exposed to the trigger situation but are not inseparably linked to the trigger,
and it is not necessary to occur immediately after exposure (e.g., panic attacks

Psychopathology - An International and Interdisciplinary Perspective

are more likely to occur during the ride, but sometimes individuals they can
drive and have no panic attacks, or they happen half an hour after the ride).
• Other types of attacks are those that occur in a special emotional context those
involving limited symptoms as well night attacks.
• Situational-induced attacks are more characteristic of social and specific
phobias. Situationally predisposed panic attacks are particularly common in
panic disorder, but can also occur in specific and social phobias.
The onset of unexpected panic attacks is necessary for the diagnosis of panic
disorder with or without agoraphobia.
The frequency and severity of panic attacks vary widely. For example, some
individuals have intermediate frequency attacks (e.g., once a week), which occur
constantly for months. Others report frequent attacks in a short period (day, week)
that are separated for a long period (weeks or months) without seizures or with rare
attacks (two per month) over a long period of time. Attacks with limited symptoms
(e.g., identical to full panic attacks, but with fewer associated symptoms) are very
common in panic disorder.
. Manifestation and diagnosis of panic disorder
. The signs and symptoms of a panic attack
The signs and symptoms of a panic attack may include hyperventilation, heart
racing, chest pain, and trembling, sweating, and dizziness, with a fear of losing
control, going crazy, or dying.
. The signs and symptoms of panic disorder
Among persons that ever had a PA only 12.8% fulfilled DSM-5 criteria for PD.In
comparison with panic attacks, panic disorder is characterized by repeated panic
attacks. Panic disorder (PD) is a chronic mental disorder with essential features
such as recurrent panic attacks, persisting concern about the attacks, and a change
in behavior as a result of the attacks [17].
The lifetime prevalence of PD is two times more likely to occur in women than in
men [32]. Age of onset for PD is a wide range between 25 and 53years regardless of
gender. Alongside the variation in age, the most probable period is the late adoles-
cence and the middle of the 1930s. A certain number of PD cases begin in childhood
or after 45years of age [33]. Panic disorder usually begins in late adolescence or
early adulthood and affects women about two times more often than men. The
median age of onset is 32. Cross-national lifetime prevalence estimates is 1.7% for
PD [18].
Individuals with PD show distinctive concern about the consequences of panic
attacks. Some fear that attacks indicate the presence of an undetected life-threat-
ening disease (e.g., heart disease), and others fear that panic attacks indicate that
they are causing, losing control, or being emotionally weak. However, patients with
PD do not necessarily show deterioration in the quality of their lives by becoming
prisoners of panic attacks [17]. Some individuals with PD significantly change their
behavior (e.g., they leave work). Concerns about the next attack or its consequences
are often associated with avoiding behavior. Hence, PD is defined as an experience
of having panic attacks and as emotional and behavioral consequences from it.

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. Diagnosis of panic disorder
To help pinpoint a diagnosis it is necessary to do:
• Complete physical exam.
• Blood tests to check the thyroid and other possible conditions and tests on heart,
such as an electrocardiogram (ECG or EKG).
• Psychological evaluation about symptoms, fears or concerns, stressful situa-
tions, relationship problems, situations that are avoided, and family history. Fill
out a psychological self-assessment or questionnaire.
• Check alcohol or other substance use.
Criteria for diagnosis of panic disorder according to ICD-10 are:
• At least 1 month many attacks with vegetative anxiety which occur in circum-
stances where there is no objective danger;
• Panic attacks are without restrictions on known and predictable situations
• There is no symptoms of anxiety between seizures (although anxiety may be
common)
• Psychological or vegetative symptoms are primary manifestations of anxi-
ety, and not secondary to other symptoms, such as crazy ideas or obsessive
thoughts;
• Anxiety must be limited to at least two of the following situations (or mainly to
occur only in them): crowds, public places, travel from home, or unaccompa-
nied travel by another person;
• Avoiding the phobic situation
A single panic attack may only last a few minutes, up to 20–30min, but can
cause serious problems in the everyday life. This can also lead to:
• Anticipatory anxiety in between panic attacks, the patient feels anxiety and
tension, because of a fear of having future panic attacks. This “fear of fear” is
present most of the time, and can be extremely disabling in everyday life.
• Phobic avoidance of certain situations or environments. This avoidance may
be based on the belief that the situation that is avoided caused the previous
panic attack, or is a place where the escape is difficult or the help is unavail-
able in case of a panic attack. Taken to its extreme, phobic avoidance becomes
agoraphobia.
. Causes of panic attacks and panic disorder
The causes have not been fully illuminated, although there are a number of
theories.

Psychopathology - An International and Interdisciplinary Perspective
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. Biological theories and pathophysiology of panic attacks and panic disorder
From biological theories, there is a genetic predisposition and disturbance in
the functioning of certain neurotransmitter systems in the brain (noradrenergic,
serotonergic, dopaminergic, GABA). During panic attack an excessive vegetative
reaction, with an increased tonus of sympathetic system is present, and also with
increased catecholamine release [20].
The exact pathophysiology of PD is currently unknown. There are theories that
functioning of serotonin, norepinephrine, dopamine and gamma-aminobutyric
acid (GABA) neurotransmitter systems play a role [42].
• The noradrenergic theory assumes that in PD presynaptic norepinephrine
auto-receptors are hypersensitive to stimulation by norepinephrine [31].
• Other clinical studies demonstrate that medications increasing the synaptic
availability of 5-HT, are effective in the treatment of PD.Rival theories of 5-HT
deficiency vs. excess attempt to explain the impact of 5-HT function in PD [41].
• Researches are indicating that GABA may play a role—PD is a result of a lack
of central inhibition and decreased GABA concentrations, leading to uncon-
trolled anxiety during panic attacks [24, 26].
. Psychological theories
As a special predisposing characteristic of people who are prone to the develop-
ment of panic disorder, the existence of anxiety character is emphasized, which is
manifest in childhood as a tendency to shame, cold and wet palms, fear of illness,
constant need for support, hypersensitivity to the opinions of others, constant fear
not to commit mistake, incompetence to accept responsibility, tranquility, scrupu-
lousness, too high expectations of oneself.
Psychological theories speak of separation fears, the austerity of the release
of sexual energy, the traumatized trauma, various misconceptions, or irrational
thoughts, etc.
• Psychodynamic theory of panic attacks describes a state of regression in which
a complete collapse of the defense defeats, anxiety overwhelms the person and
is “empty” through panic states.
• Behavioral theory stresses that anxiety can be learned through the identifica-
tion of the parent behavior model, then anxiety that develops after experienc-
ing frightening stimuli, such as accidents, that are transmitted to other stimuli,
as well as anxiety due to frustration that becomes a conditioned response to
other stressful situations.
. Researches: causes for panic attack and panic disorder
.. Genetic
Several studies have shown that the risk of PD is eight times higher in those with
first-degree relatives with PD compared to those with no family history [40, 55].
Recent studies examine twins and estimate that the heritability of panic disorder is
30–40%.

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A review of family and twin studies shows the highly familial nature of panic
disorder and suggests evidence for a genetic etiology. The population-based life-
time rates of panic disorder cross-nationally range between 1.2/100 and 2.4/100,
whereas, the lifetime rates in first-degree relatives of panic probands range between
7.7/100 and 20.5/100 [66].
.. Environmental
Combination of genetic and environment interactions can produce panic disor-
der [60]. Major stress and temperament that is more sensitive to stress or prone to
negative emotions are connected with a onset of PD including major life transitions
such (graduating from college and entering the workplace, getting married, or hav-
ing a baby), and other severe stress (death of a loved one, divorce, or job loss) [21].
The aversive childhood events such as physical or sexual abuse have been associated
with an increased risk of PD in adulthood [9, 10, 25].
.. Other
Asthma and smoking also have been associated with an increased risk of PD
[13, 28]. Panic attacks can also be caused by medical conditions and other physical
causes like mitral valve prolapse or hyperthyroidism [2, 34]. Substance abuse, espe-
cially stimulants (amphetamines, cocaine, and caffeine), may also be connected
with the onset of panic attacks and PD.
. Complications of panic attacks and panic disorder
Complications that panic attacks and panic disorders may cause avoidance of
social situations, problems at work or school, depression with suicidal thoughts,
substance abuse.
. Treatment for panic disorder
The first contact of patient with PD usually is with a family physician. Due to
the presence of numerous physical symptoms of panic attack, many people ini-
tially perform different somatic tests, from routine, to more complex, to internal
and neurological examinations, and fail to timely initiate treatment. This is why
the role of a family physician is important in recognizing and treating the disorder,
or referring to a psychiatrist. Unfortunately only a minority of patients with panic
disorder receive adequate care. One of the reasons is that about 50% of patients
seek help [27, 36, 43].
Treatment of panic disorder should in no way be limited to providing first aid
during panic attacks (usually by injection of diazepam intramuscularly as an emer-
gency) without planning a targeted and ongoing treatment. The main treatment
options are psychotherapy and medications. Combination of them is considered as
the most effective [3].
. Psychotherapy
Psychotherapy can help to understand panic attacks and panic disorder and
learn how to cope with them.

Psychopathology - An International and Interdisciplinary Perspective

• Individual therapy: That is, the most usual form of psychotherapy when deal-
ing with panic disorder, but also other form of psychotherapy can be applied.
• Group therapy: Group therapy has positive sides because by sharing the experi-
ences with others, people are creating opportunities for reinforcement by the
others and decreasing their shame.
• Couples and family therapy: Symptoms of panic disorder usually affect the
relations among the members in the family. Family and couple therapy helps
them to improve the communication and to support the person with panic
attack or disorder in an appropriate way.
.. Psychoanalysis and psychodynamic therapy
Psychoanalysis and psychodynamic therapy deals with problematic behavior,
feeling, or thought by finding their unconscious meaning. When focused on panic
deal with core conflicts in the person which are involving aggression and fear-
ful dependency, or other intrapsychic conflicts that can also contribute to panic
symptomatology [45].
.. Cognitive behavioral therapy
Cognitive-behavioral therapy involves teaching patients to recognize their
distorted thinking. The goal is to clarify the patient’s misinterpretation of the physi-
cal symptoms of panic attack and act on avoiding behavior by gradually exposing
the situations that led to the attack. Useful relaxation exercises as well as regular
breathing exercises, with moderate physical activity, are also useful.
In cognitive-behavioral treatment of panic disorder patients learn useful infor-
mation about how and why anxiety, fear and panic occur, learn to apply various
relaxation techniques, go through a gradual exposure to situations that create fear
when are prepared, learn how their thoughts, assumptions and beliefs about anxiety
and panic and their consequences worsen their problem and how they can deal
with them, along with the therapy they go through various experiments to test their
beliefs about fear and panic, and find out what to do in case of panic attacks [14].
Research shows that CBT efficacy is between 85 and 90% for treatment consist-
ing of 12–15 meetings. In addition, most of the participants maintained this prog-
ress a year after treatment when monitored. Some studies have shown that CBT is at
least as successful in the treatment of panic disorder as pharmacotherapy, but that
treatment has been more prolonged by CBT.Namely, in CBT, an individual learns
strategies to efficiently cope with his anxiety that is the skill he can use for his entire
life [1, 49, 51, 67].
.. Humanistic therapy
Humanistic therapy (client-centered therapy, gestalt therapy, and existential
therapy) is focused on people’s capacities to make rational choices to use their
potential and to accept the responsibility for themselves. It helps people to under-
stand what is happening with them and to focus on the present by making new,
more functional choices [65].
.. Self-help tips for panic attacks
The following self-help techniques can make a difference to overcome panic:

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Panic Attacks and Panic Disorder
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• Learn about panic and anxiety.
• Learn how to control your breathing. Deep breathing can relieve the symptoms
of panic.
• Practice relaxation techniques—yoga, meditation, muscle relaxation to increase
feelings of joy and equanimity.
• Exercise regularly. At least 30min on most days (three 10-min sessions is
just as good) like walking, running, swimming, or dancing can be especially
effective.
• Connect face-to-face with family and friends. Symptoms of anxiety can become
worse when you feel isolated, so building supportive friendships can help.
• Avoid smoking, alcohol, and caffeine.
• Get enough restful sleep [4].
. Pharmacotherapy
There are a large number of drugs that have been studied in patients with panic
disorder, but no drug has proven superior to other drugs used in the treatment of
patients with panic disorder. Pharmacological agents with sufficient evidence to
support their use in the treatment of panic disorder include:
• Antidepressants—selective serotonin reuptake inhibitors (SSRIs), serotonin
noradrenaline reuptake inhibitor (SNRI), tricyclic antidepressants (TCAs) and
• Benzodiazepines [8, 37].
.. Antidepressants
The modern treatment of panic disorder is based on the use of antidepressants
from the selective serotonin reuptake inhibitor (SSRI) and antidepressants from the
serotonin and noradrenaline reuptake inhibitor (SNRI). Use of these drugs has less
danger of creating addiction and abuse than benzodiazepines. The disadvantage
of these antidepressants is delayed by the onset of the positive effect and adverse
effects that occur during treatment.
Clinical studies have demonstrated the significant efficacy of SSRI/SNRI drugs
in the treatment of panic disorder. Certain differences in medication do not occur
in terms of efficacy, but can be observed in terms of side effects, drug delivery
methods during their use, and the occurrence of deterioration in dose reduction
and upon discontinuation of the drug. Therefore, it is important to pay attention to
these factors in the individual selection of medicines. The dosage of antidepressants
effective in panic disorder is shown in Table  .
... Efficacy of antidepressants in acute phase treatment of panic disorder
Antidepressants acting on the serotonergic system—citalopram, fluvoxamine,
fluoxetine, paroxetine, sertraline [8, 16, 46, 61], the SNRIs venlafaxine and
duloxetine [15, 35, 38, 58], and the TCAs imipramine and clomipramine [5, 39] are
effective in treating acute phase of panic disorder.

Psychopathology - An International and Interdisciplinary Perspective

... Efficacy of antidepressants in long-term treatment of panic disorder
The SSRIs i.e., citalopram, fluvoxamine, paroxetine, the SNRIs venlafaxine and
duloxetine and the TCAs, all remain effective in the treatment of panic disorder
over the long-term [5, 15, 22, 52].
... Side effects of antidepressants
In order to avoid or at least alleviate adverse effects, it is recommended that the
starting daily dose of antidepressant drugs be lower than the recommended effec-
tive dose, and that the daily dose increase will be gradual in the first weeks of treat-
ment. Psycho-education of patients with panic disorder about side effects and slow
onset of action of antidepressants is very important. The assessment of outcome
should be made only after several weeks of treatment.
... Dropout rates in treatment of panic disorder with antidepressants
During pharmacological treatment of panic disorder 18% of patients treated
with SSRIs, 1–12% of patients treated with venlafaxine and about 30% of patients
treated with TCAs dropout prematurely [5, 50, 64].
.. Benzodiazepines
There are a number of clinical studies, with many years of experience, which
indicated that benzodiazepines are effective in treating patients with panic disor-
ders. The benzodiazepines are superior to placebo in the acute phase treatment of
panic disorder [11, 63]. They have strong effects on somatic symptoms of anxiety
and sleep problems. In addition, Benzodiazepines have a fast onset of action, i.e.,
they produce effects as soon as an effective dose is administered. For half an hour
to an hour after taking benzodiazepine, panic symptoms are reduced, and patients
feel easier. No other drug can do this [11]. The correct dosage of benzodiazepine
involves a gradual increase in dose to a dose that removes symptoms and does not
Drug name Start Recommended Maximum
Antidepressants SSRIs (mg/day)
Citalopram 10 20–40 40
Escitalopram 510–20 20
Fluoxetine 10 20–40 60
Paroxetine 10 20–40 60
Sertraline 50 50–100 150
SNRIs
Venlafaxine 3 7. 5 75–225 300
Duloxetine 30 60–120 120
TCAs
Clomipramine 25 100–150 250
Imipramine 25 100–150 300
Table 1.
Dosage of antidepressants effective in panic disorder.

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Panic Attacks and Panic Disorder
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cause significant adverse effects, with regular taking more than once a day. Dosage
of benzodiazepines effective in panic disorder is shown in Table .
... Length of treatment with benzodiazepines
Due to the possible occurrence of dependence and abstinence syndrome, the
duration of therapy with benzodiazepines should be short, for several weeks.
However, because of the chronic character of the disease, sometimes they should be
administered for several months, even for a year with continuous monitoring of the
patient [47].
... Side effects and risks involved in treatment with benzodiazepines
When benzodiazepines are prescribed for long-term use, dependence may occur
manifested by dose escalation and problems withdrawing the medication [47, 63].
... Dropout rates in treatment with benzodiazepines
In panic disorder trials, dropout rates due to side effects are about 15% for
benzodiazepines [47].
.. First-line pharmacotherapy of panic disorder
SSRIs and venlafaxine should both be considered first-line agents for treatment
of panic disorder. SSRIs and venlafaxine are effective in acute and long-term treat-
ment, have an acceptable side effect profile and acceptable dropout rate [16, 48, 57].
TCAs may have a slower onset than SSRIs. In addition, TCAs have a less toler-
able side effect profile than SSRIs given that they have more anticholinergic effects,
and are generally less safe than SSRIs. Finally, reported dropout rates are higher for
TCAs compared to SSRIs [5, 6, 62].
In summary, benzodiazepines as monotherapy should not be regarded as a first-
line treatment in view of their side effect profile and in view of their lack of efficacy
in treating comorbid conditions.
.. Optimal duration of pharmacotherapy of panic disorder
Studies reported that more than half of the patients interrupt treatment within
several months to years [62, 64]. But considering, often relapsing course of panic
disorder long-term treatment is recommended [3, 7, 12, 22, 43]. Most guidelines
refer to expert consensus and suggest pharmacotherapy for at least a year [6].
Benzodiazepines
Drug name Start Recommended Maximum
Alprazolam 12–4 6
Clonazepam 0.25–0.5 1.5–3 6
Diazepam 5–10 40–50 50
Lorazepam 1–3 2.5–7.5 10
Bromazepam 33–9 15
Table 2.
Dosage of benzodiazepines effective in panic disorder.

Psychopathology - An International and Interdisciplinary Perspective

Providing psychotherapy to panic disorder patients is also beneficial in enhanc-
ing the long-term outcome. Some evidence indicates that a CBT relapse-prevention
program prevents relapse in patients with panic disorder [23, 59].
.. Pharmacotherapy in treatment-refractory patients with panic disorder
Some panic disorder patients do not respond, or only respond partially to phar-
macotherapy. The treatment of refractory patients should consist of optimizing
the current treatment, switching to another agent, or augmentation. Optimizing
the current pharmacotherapy may be useful but some studies reported that an
increased dosage of a SSRI is no more effective [8, 43].
Switching within or between classes of pharmacological agents, or to another
treatment modality with proven efficacy in treating panic disorder, such as CBT,
may be effective [23, 29, 53, 57].
Augmentation of antidepressants with an antipsychotic has been suggested for
refractory panic disorder patients [30, 54, 56].
. Conclusion
Panic disorder is a prevalent and disabling disorder with unknown etiology.
Panic disorder should be diagnosed as soon as possible and to start the treatment
which can be effective. The main treatment for panic disorder is psychotherapy
and medication. One or both types of treatment may be recommended, depending
of the patient preference, his history and the severity of the panic. The first-line
treatment of panic disorder usually is CBT and pharmacotherapy with SSRIs. The
recommendations are at least a year of antidepressant treatment. Management of
treatment-refractory panic disorder includes a range of switching and augmenta-
tion strategies. Psychotherapy helps patients to overcome their fears usually within
several months, but occasional visits afterward can help them to ensure that panic
attacks are under control.
Conflict of interest
The authors declare that there is no conflict of interest.
Author details
DimitarBonevski and AndromahiNaumovska*
Faculty of Medicine, St. Cyril and Methodius, Skopje, North Macedonia
*Address all correspondence to: andromahi_n@yahoo.com
© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms
of the Creative Commons Attribution License (http://creativecommons.org/licenses/
by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly cited.

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Panic Attacks and Panic Disorder
DOI: http://dx.doi.org/10.5772/intechopen.86898
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