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What Is Panic Disorder: DSM-5 Criteria

December 1, 2018

 

Anyone who experiences frequent panic attacks, worries about future panic attacks, and changes their behavior because of it, could be diagnosed with Panic Disorder if these symptoms persistent beyond one month. 

 

In a 12-month period, it is estimated that approximately 11.2% of adults in the United States and up to 3.3% of Europeans experience panic attacks. 

 

The American Psychological Association (APA) reports that 1 out of 75 people might experience panic disorder.

 

Although children can also experience panic attacks, the average age of onset is 22-23 years of age. 

 

Panic attacks are more common in women than men but the symptoms remain the same for both men and women.

 

 

What is a Panic Attack?

 

A panic attack is a very brief episode of intense fear and discomfort.

 

Note that a panic attack can occur from a calm state or an anxious state.

 

Symptoms reach a peak within minutes and then subside within minutes. A person may return to a reduced state of anxiety or to a state of calm.

 

A panic attack is the body’s evolutionary response to a perceived external threat.

 

The fight, flight, or freeze response is helpful if we encounter a wild animal poised to eat us. 

 

The adrenaline that begins flowing through our bodies aids in our escape and survival. When the external threat is defeated or evaded, the symptoms disappear. 

 

For most people today, however, there is no wild animal. It’s a false alarm that signals an internal threat or danger. It’s a misperception of danger.

 

After experiencing a first panic attack, the fear becomes about experiencing another one. 

 

 

DSM-5 Diagnostic Criteria for Panic Disorder

 

The Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) defines Panic Disorder as recurrent and unexpected panic attacks that can be diagnosed if one or more of the following symptoms occur:

 

  • Pounding heart

  • Sweating

  • Trembling

  • Shortness of breath

  • Feelings of choking

  • Chest pain

  • Nausea

  • Feeling dizzy

  • Faintness

  • Feelings of unreality (Derealization) or feeling detached from your body (Depersonalization)

  • Fear of losing control or going crazy

  • Fear of dying

  • Numbness or tingling

  • Chills or hot flashes

These symptoms must also be followed by 1 month or more of worry about future panic attacks and unhelpful behavior aimed at trying to control it such as avoidance.

 

Panic attacks can be expected or unexpected. 

 

An example of an unexpected panic attack is called a nocturnal panic attack. This is when a person wakes from sleeping in a state of panic. 

 

Expected panic attacks occur in specific situations that are either anxiety provoking or situations where a person experienced a panic attack and now avoids it for fear that it will trigger another one. 

 

Specific phobias such as fear of flying and public speaking could also trigger a panic attack due to increased anxiety and fear of the event itself.

 

People will often avoid situations that either trigger panic attacks, situations that just become associated with panic attacks, or places where escape to safety may be difficult. 

 

In extreme cases people stop leaving their homes and become agoraphobic or fearful of a wide range of situations that feel unsafe. 

 

Panic attacks also may occur with Obsessive Compulsive Disorder (OCD), Post-Traumatic Stress Disorder (PTSD), and with Depression.

 

 

What are the Risk Factors for Panic Disorder?

 

Family history of anxiety: Some research indicates that first-degree relatives of patients with panic disorder have higher rates of panic disorder than relatives of patients with major depression and relatives of healthy controls (Goldstein et al 1994).

 

Respiratory illnesses: Conditions such as asthma can cause breathing issues that lead to shortness of breath and feeling dizzy. This could cause the fear of internal physical danger, triggering a panic attack.

 

Environment: Physical and psychological abuse, traumatic events, the death of a loved one, divorce, abandonment, and maladaptive behaviors learned from parents pose a greater risk for the development of an anxiety disorder such as panic disorder. 

 

Those with an anxiety disorder may have inherited anxiety from their families as a result of stressful family and life circumstances.

 

Other anxieties: Other anxieties such as PTSD, social anxiety, and phobias all have the potential risk to trigger panic attacks.

 

 

What Causes Panic Disorder?

 

Beyond other anxiety disorders, fears, and worry there are physical and mental processes responsible for panic attacks and anxiety.

 

They are evolutionary biological processes that are meant to help us in times of danger but often become a nuisance when there is no danger.

 

Catastrophic thinking

 

Catastrophic thinking causes the amygdala to turn on the body's fight or flight or freeze stress response and triggers the vicious cycle of panic.

 

The Vicious Cycle of Panic

 

  • The Trigger can be a thought or a situation

 

  • ​You then Perceive Danger. The thought or situation can be of an internal (Physical) or external (Phobic) threat. An example of an unhelpful thought for an internal threat is “My heart feels like it is beating fast. I must be having a heart attack.” An example of an unhelpful thought for an external threat is, “This plane that I’m on could crash.” 

 

  • This sends a message to your amygdala to sound the alarm and causes more Fear and apprehension of the perceived danger. 

 

  • The sympathetic nervous system automatically kicks in and increases physical Body Sensations (pounding heart, sweating, shaking).

 

  • You Label the Sensations as Catastrophic, you have a panic attack, and this confirms the danger. 

 

Your Perceived Danger increases and the cycle continues. This becomes a vicious cycle of panic. Avoiding the situation or running away also falsely confirms that the danger is real and gives more power to future panic attacks.

 

 

Sympathetic nervous system

 

The sympathetic nervous system is responsible for the “Stress Response” also called the “Fight or Flight or Freeze Response” in order to provide us with the internal resources to deal with a real threat or danger.

 

Just remember that the sympathetic nervous system "Sympathizes" with you in times of danger. 

 

It is fast, automatic, and is activated mostly without your conscious control. It is responsible for the physical sensations of panic or the fight, flight, and freeze stress response.

 

 

Amygdala

 

During times of stress or danger, your senses send messages to your amygdala in the brain. 

 

The small almond shaped amygdala is your emotional center and is responsible for causing the emotional feeling of fear.  ​

 

When your amygdala gets the message that there is danger, it sounds the alarm for your sympathetic nervous system to release adrenaline to help you react to the danger. This causes the symptoms you feel during a panic attack.

 

The thinking part of your brain also gets this message so that you can determine if the danger is real or not. If you have the thought or belief that the danger is real, then your amygdala will get that message from your thoughts and it will continue to sound the alarm which will cause your hypothalamus to dump more hormones into your blood stream, further fueling a panic attack.

 

  

Psychological Issues

 

With Panic Disorder, the main issue is worry and fear of having future panic attacks after experiencing your first panic attack.

 

The reason your panic attacks started in the first place, however, is usually related to something other than fear of a panic attack. It’s something deeper. 

 

There may be a psychological issue fueled by underlying feelings and beliefs created by past experiences. We can often trace the root causes for our current psychological issues back to negative experiences beginning in early childhood and extending to early adulthood.

 

Early experiences with loss, abandonment, trauma, abuse, being bullied in school, and any other stressful experiences could have instilled a sense of uncertainty and helplessness.  

 

These experiences contribute to the development of our beliefs and attitudes about our self and about the world. 

 

If your negative beliefs and attitudes are not identified and go unchallenged, they will continually influence your current thoughts, feelings, behaviors, and situations.

 

A current death of a loved one or some other kind of loss could trigger the belief that the world is a dangerous place and that you are vulnerable and helpless. 

 

Depression and anxiety disorders can manifest from these beliefs and lead to a number of emotional, physical, and behavioral symptoms such as panic attacks. 

 

Even if you learn how to cope with panic attacks, you will still be at risk for future panic attacks if the underlying causes of depression and anxiety are not treated.

 

 

What Is The Treatment for Panic Disorder?

 

If you believe you could have Panic Disorder it will be helpful and important to seek consultation with a mental health professional to first verify the diagnosis and then receive appropriate treatment.

 

Treatment often consists of a combination of medication and psychotherapy. Medication helps take the edge off the physical symptoms of anxiety and psychotherapy helps to challenge irrational thinking and beliefs that lead to the panic attacks.

 

 

Cognitive Behavioral Therapy (CBT)

 

Cognitive Behavioral Therapy (CBT) is a well-researched and highly effective form of talk therapy that focuses on learning more helpful ways of thinking and behaving. 

 

You learn different ways of responding to the symptoms of a panic attack. 

 

CBT helps challenge and change unhelpful beliefs that cause anxiety by restructuring your automatic thinking.

 

CBT sessions also provide education on the symptoms of panic disorder. 

 

Cognitive Restructuring

 

Cognitive restructuring is used to identify and dispute unhelpful, automatic, and irrational thinking so that you can create highly effective thoughts with the power to alter your emotions and behavior. 

 

An example of an irrational thought is “What if I can’t escape from that place.  I’ll have a panic attack and lose control.”

 

We develop beliefs about ourselves, other people, and the world.  These beliefs influence how we think. 

 

If you believe that the world is basically a dangerous place, then your thoughts will follow. If you believe that you are defective and not a capable person, then your thoughts will reflect those beliefs.

 

It is not the public place that causes the anxiety, it’s your thinking and beliefs that cause the fear and anxiety.

 

 

Exposure Therapy

 

Exposure therapy, also known as prolonged exposure, is a form of CBT. 

 

As with most anxiety disorders, in order to learn how to overcome the symptoms of panic disorder, you need to have the experience of successfully managing the symptoms. 

 

This often means exposing yourself to the thoughts, images, and the public places that trigger the panic attacks, and then applying the coping strategies until the thoughts, images, and public places no longer produce the same level of fear.

 

 

Medication

 

Please consult with your primary care physician or a psychiatrist regarding the use of any medication.

 

Medication can help reduce the symptoms of anxiety that occur in public situations that you have been avoiding such as school, work, and any other necessary public location. 

 

Commonly prescribed medications include benzodiazepines and anti-depressants.

 

Benzodiazepines are quick acting sedatives that are generally safe and effective for short term use. However, the long term use of benzodiazepines is associated with the risk of developing tolerance, dependence, and possible other adverse effects. 

 

 

Commonly prescribed benzodiazepines are:

 

  • Alprazolam (Xanax)

  • Lorazepam (Ativan)

  • Diazepam (Valium)

  • Clonazepam (Klonopin)

 

Anti-depressant medications are also effective at reducing symptoms of anxiety on a daily basis. This helps dampen the physical and emotional effects of anxiety and increases a person’s capacity to cope with stressful situations. 

 

 

Commonly prescribed anti-depressants are:

 

  • Citalopram (Celexa)

  • Escitalopram (Lexapro)

  • Sertraline (Zoloft)

  • Paroxetine (Paxil)

  • Fluoxetine (Prozac)

 

Beta Blockers are used to treat high blood pressure, heart arrhythmias, and migraines. 

 

They are also prescribed for off-label use by physicians to help reduce the physical symptoms of anxiety. 

 

Beta blockers have the ability to control rapid heartbeat, shaking, trembling, and blushing in response to a panic attack.

 

Beta blockers do not interfere with cognitive performance and are by far my favorite for removing the jitters before a speech.

 

Commonly prescribed Beta Blockers:

 

  • Propranolol (Inderal)

  • Atenolol (Tenormin)

  • Acebutolol (Sectral)

  • Bisoprolol (Zebeta)

  • Metoprolol (Lopressor, Toprol-XL)

  • Nadolol (Corgard)

  • Nebivolol (Bystolic)

 

For more information:

 

Please purchase my book “Attacking Panic:  The Power to Be Calm” for more in depth information on how to stop panic attacks quickly and how to treat the root cause (Amygdala/Sympathetic Nervous System). 

 

The book shows you how to go beyond just giving up control and allowing yourself to experience a panic attack.  

 

The book has more powerful strategies that will short-circuit your fight or flight system, stop a panic attack very quickly, and even prevent a panic attack from occurring.

 

How to stop panic attacks: 

How to Stop A Panic Attack: 7 Steps 

What To Do In A Panic Attack: 4 Great Ways to Cope 

Panic Attacks In Children - How To Help Your Child

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Russell Hunter, Psy.D.
Licensed Clinical Psychologist

I want to help you. Please feel free to contact me confidentially by email below with any questions or if you need some advice about the content posted on The Fear Blog.

Attacking Panic: The Power To Be Calm. Copyright © 2017 Russell A. Hunter, Psy.D. All rights reserved. Attacking Panic is available in paperback and Kindle edition at Amazon and in paperback at Barnes & Noble and other online retailers.

How to Stop A Panic Attack Quickly.

Russell A. Hunter, Psy.D. Psychology Today Profile

National Register of Health Service Psychologists

8644 Sudley Road, Suite 315 Manassas VA 20110

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