Panic Disorders: Symptoms and Diagnostic Considerations
For most of the two percent of Australians affected by panic disorder, the onset was during their teens or early twenties. It is twice as common in women as men. Not everyone who has panic attacks will develop panic disorder, as some people will have just one attack and never have a recurrence. The tendency to incur panic attacks appears to be inherited (The Royal Australian and New Zealand College of Psychiatrists, 2009).
The symptoms, stated below, can be very disabling, and sufferers of attacks are advised to seek help as soon as possible after an attack, or the recurrence of an attack, because the tendency is to avoid increasing numbers of places or situations where attacks have occurred (NIMH, n.d. — b). We list below the nested hierarchy of symptoms by which are defined first panic attacks, then panic disorder, and finally agoraphobia.
Panic attacks are sudden, extreme feelings of fear and/or discomfort often peaking within a few minutes and often lasting no more than 10 minutes (although 20 to 30 minutes is possible) before subsiding. The DSM defines them as an incident in which someone has at least four of the following symptoms, divided into somatic and cognitive categories:
- Palpitations and/or pounding heart
- Shortness of breath or feeling of being smothered
- Chest pain or discomfort
- Choking sensation
- Trembling or shaking
- Nausea or abdominal discomfort
- Feeling dizzy, lightheaded, unsteady, or faint
- Numbness or tingling
- Hot flashes or chills
- De-realisation or depersonalisation (a sense of things being unreal or feeling detached from oneself)
- Fear of dying
- Fear of losing control or going crazy (Jacofsky, Santos, Khemlani-Patel, & Neziroglu, 2013; ADAA, 2014; Otto & Murray, n.d.)
- When a person experiences fewer than four symptoms, it is known as a limited-symptom panic attack. In these cases, the most common symptom is shortness of breath, due to hyperventilation.
Panic attacks are characterised by perception of danger occurring in the present moment, as opposed to other anxiety disorders, which are future-oriented (that is, worry about what might happen). Panic attacks are generally accompanied by intense fear or terror, a sense of doom, and a need to escape. Once they begin, they tend to recur (Jacofsky et al, 2013).
Panic disorder is characterised by recurrent unexpected panic attacks. The other criterion in the DSM-5 is that there is:
- Worry about future attacks
- Worry about the consequences of the attack (i.e., having a heart attack)
- Substantial behavioral changes in response to the attacks as the person attempts to avoid situations, persons, and places which he or she fears may trigger another attack (Otto & Murray, n.d.)
It is important to note that panic disorder is often accompanied by other health problems, such as depression or substance abuse; these conditions need to be treated separately, but the presence of symptoms related to them can mask the panic, making diagnosis of the panic disorder difficult (NIMH, n.d. -b).
People who experience repeated attacks can become significantly disabled by their condition. About one-third of people with panic disorder go on to develop agoraphobia — literally meaning “fear of open spaces” — in which they avoid public places where immediate escape might be difficult (ADAA, 2014). They come to have lives so restricted that they avoid normal activities, such as driving or grocery shopping; they may be limited in where they are willing to live, work, or recreate, especially in instances where an attack may have occurred, say, in a lift (no more living in fifteenth floor flats!), or on a particular road (forget that neighbourhood altogether!). Agoraphobics often become housebound or perhaps they only feel able to face a feared situation accompanied by a spouse or other “safe” person. The clinical characterisation is that agoraphobia:
- Entails anxiety about being in situations related to perceived inability to escape or get help if a panic attack occurs
- Causes sufferers to avoid situations or endure them with significant distress
Early treatment can often prevent panic disorder developing into agoraphobia. However, because many of the symptoms mimic those of illnesses such as heart disease, thyroid problems, and breathing disorders, people with panic disorder sometimes go from doctor to doctor for years, visiting emergency departments repeatedly — convinced they have a life-threatening illness and frustrating everyone — before the health professionals attending them correctly diagnose their condition (Otto & Murray, n.d.; NIMH, n.d. — b). In fact, many people suffering from panic attacks do not know that they have a real and treatable disorder (Government of Canada, 2013). This is unfortunate, because as we will see, panic disorder is one of the most treatable anxiety disorders of all.
The core patterns of panic disorder
As we have been noting, one of the main problems with panic disorder is not the danger presented by symptoms themselves; rather, it is the person’s fears of symptoms of anxiety, also termed “anxiety sensitivity”. This puts the person who has experienced panic attacks at heightened risk:
- For onset of more panic attacks
- For biological provocation of panic (e.g., through reactions such as hyperventilation which induces panic symptoms)
- For panic disorder relapse (Otto & Murray, n.d.)
Let’s look at the dynamic here. A panic attack is different from a fear reaction. Of course, both of them involve the fight-or-flight response, but a fear response is a reaction to a very clear and present danger; it results in our internal alarm system giving us a true alarm. If you fall down onto the tracks at the subway station just as you notice a train steaming into the station, you have an excellent reason to be alarmed! A panic attack, conversely, occurs without any clear or present danger, and results in a false alarm. An example here is the person who is afraid of trains merely because they once had a panic attack in one. Unfortunately for serenity, the body does not distinguish between a true alarm and a false one, setting into motion the same sensations, cognitions, and emotions for a false alarm as for a true one (Jacofsky et al, 2013).
Cued and un-cued attacks
Panic attacks occur in the context of several different anxiety orders, so it is important to distinguish between two different types of attacks in order to make an accurate diagnosis. Unexpected or uncued panic attacks seem to come from out of nowhere, without an identifiable source to set them off. Mental health experts believe that such attacks are in response to some kind of life stress, but the stress is often outside the awareness of the person experiencing it. For example, a person who must fly to another city for a job interview but is afraid of flying may have a panic attack while shopping for a suit to wear to the interview. The candidate may not see any connection between the actions of suit-shopping and panic, but the attack may well have been triggered by the fear of the imminent plane ride to the interview.
Conversely, expected or cued attacks are those with an obvious cue or trigger. They often occur when a person is exposed to situations or objects where panic attacks have occurred before. The onset of such an attack is sudden and occurs immediately upon exposure. This type of panic attack is most often associated with social anxiety disorder, specific phobias, and agoraphobia (Jacofsky et al, 2013). An example of a cued attack is someone who invariably gets a panic attack when they go to the mall, where they first had an attack.
- ADAA (Anxiety and Depression Association of America). (2014). Panic disorder and agoraphobia: Symptoms. ADAA. Retrieved on 3 September, 2014, from: hyperlink.
- Government of Canada. (2013). Statistics Canada: Section B, anxiety disorders: Panic disorder. Retrieved on 16 September, 2014, from: hyperlink.
- Jacofsky, M.D., Santos, M.T., Khemlani-Patel, S., & Neziroglu, F. (2013). Panic attacks: A classic symptom of several anxiety disorders. MentalHelp.net. Retrieved on 2 September, 2014, from:hyperlink.
- National Institute of Mental Health. (n.d. — b). Anxiety disorders: Panic disorder. National Institute of Health, a component of the United States Department of Health and Human Services. Retrieved on 3 September, 2014, from: hyperlink.
- Otto, M.W. & Murray, H.W. (n.d.) Cognitive behavioral treatment of panic disorder. Center for Anxiety and Related Disorders, Boston University: Power Point slide show: R25 MH08478. Retrieved on 2 September, 2014, from: hyperlink.
- The Royal Australian and New Zealand College of Psychiatrists (RANZCP). (2009). Panic disorder and agoraphobia: Australian treatment guide for consumers and carers. RANZCP. Retrieved on 17 September, 2014, from: hyperlink.