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Panic disorder

Introduction

Everyone experiences feelings of anxiety and panic during their lifetime. It is a perfectly natural response, particularly when you are in a dangerous or stressful situation.

However, for people with panic disorder, feelings of anxiety, stress and panic can occur at any time, usually for no obvious reason.

Anxiety conditions

There are several conditions where anxiety is one of the main symptoms. Phobias, generalised anxiety disorder (GAD), and post-traumatic stress disorder, can all cause severe anxiety.

Panic attacks

A panic attack is when your body experiences a sudden rush of intense psychological (mental) and physical symptoms.

You may feel an overwhelming sense of fear, apprehension, and anxiety. As well as these feelings, you may also experience physical symptoms, such as nausea, sweating, trembling, and a sensation that your heart is beating irregularly (palpitations).

A panic attack can be very frightening and intense, but it is not dangerous. It will not cause you any physical harm.

How common is panic disorder?

At least 1 in 10 people have experience occasional panic attacks, which are usually triggered by a stressful event, or situation. However, people with panic disorder have attacks on a regular and recurring basis, usually for no apparent reason.

The number of panic attacks that you have will depend on the severity of your condition. Some people may have one or two attacks each month, while others may have several attacks a week.

Because panic disorder is a very unpredictable condition, it leaves people with the disorder feeling constantly anxious and concerned about when their next attack will be.

In the UK, approximately 1 in 100 people have panic disorder. Most people first develop the disorder during their 20s, and it is approximately twice as common in women than it is in men. 

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Symptoms

The symptoms of a panic attack can be very frightening and distressing. Symptoms tend to occur very suddenly, without any warning, and often for no apparent reason. As well as overwhelming feelings of anxiety, a panic attack can also cause the following symptoms:

  • dizziness,
  • feeling faint,
  • sensation that your heart is beating irregularly (palpitations),
  • sweating,
  • trembling,
  • shortness of breath,
  • nausea,
  • chest pain
  • numbness, or pins and needles,
  • chills,
  • hot flushes
  • choking sensation,
  • dry mouth,
  • a need to go to the toliet,
  • ringing in your ears, and
  • a feeling of dread, or a fear of dying.

The symptoms of a panic attack can be so intense that it can make you feel like you are having a heart attack. The fear of having a heart attack can then add to your sense of panic.

However, it is important to be aware that symptoms such as a racing heart beat, or shortness of breath, will not actually lead to you having a heart attack. Although frightening, a panic attack will not cause you any physical harm. People who have had panic disorder for some time will usually learn to recognise this 'heart attack sensation', and will be more aware of how to control their symptoms.

The symptoms of a panic attack normally peak within 10 minutes. Most attacks will last for between 5-30 minutes.

Recurrent panic attacks

People with panic disorder have panic attacks on a recurring basis. Some people with the condition have panic attacks once or twice a month, while others have attacks several times a week.

People with panic disorder also tend to have ongoing and constant feelings of worry and anxiety. Because panic attacks can be very unpredictable, if you have panic disorder, you may feel stressed and worried about when your next attack will be.

Depersonalisation

During a panic attack, your symptoms can feel so intense and out of your control that you may feel detached from the situation, almost as though you are an observer. It can make the situation seem very 'unreal'.

This sense of detachment is known as depersonalisation. Being detached from the situation does not provide any relief, or make a panic attack less frightening. Instead, it often makes the experience more confusing and disorientating.

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Causes

As with many conditions which affect your mental health, the exact cause of panic disorder is not yet fully understood. 

It is thought that the disorder is most likely caused by a combination of physical and psychological factors. Some of these factors are outlined below.

  • Stressful or traumatic experiences in your life, such as a bereavement, can sometimes trigger feelings of panic and anxiety. These feelings may be apparent soon after the event, or they may unexpectedly be triggered years later.
  • Having a close family member with panic disorder may increase your risk of developing the condition. However, the precise nature of the risk is not yet known.

  • Neurotransmitters are chemicals that occur naturally in your brain. It is thought that if you have an imbalance of these chemicals, it may increase your risk of getting conditions such as panic disorder.

Fight or flight reflex

Some researchers believe that panic disorder is closely associated with your body's natural 'fight or flight reflex'.

This reflex is your body's way of protecting you from stressful and dangerous situations. In a dangerous situation, anxiety and fear trigger your body to release hormones, such as adrenalin. This causes your breathing and heart rate to increase, helping you to prepare you for the situation.

When you are faced with a dangerous or frightening situation, your body reacts in a very similar way to a panic attack. However, with panic disorder, there is usually no obvious trigger for your symptoms. Researchers believe that your fight or flight reflex may be triggered abnormally in people who have panic disorder.

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Diagnosis

Panic attacks

Everyone who has panic disorder will experience panic attacks. However, not everyone who experiences panic attacks is diagnosed with panic disorder.

Some people have panic attacks in response to specific situations. For example, they may have a phobia of enclosed spaces (claustrophobia), and therefore experience panic attacks when faced with an enclosed space.

However, most people with phobias will only experience panic attacks when they are faced with whatever triggers their fear. The panic attacks of people with panic disorder are usually triggered without warning. For people with panic disorder, a panic attack often seems to occur for no obvious reason.

Your GP will diagnose you with panic disorder if you experience recurrent and unexpected panic attacks. These attacks should also be followed by at least one month of continuous worry or concern about having further attacks.

Talking to your GP about how you feel is very important

When you visit your GP, they will ask you to describe what symptoms you have been experiencing. They will also ask you how often your symptoms appear, and in what situations they occur. It is important to tell your GP about how you have been feeling, and how your symptoms have affected you.

Sometimes, it can be difficult to talk about your feelings, emotions and personal life with someone else. Try not to feel anxious or embarrassed. Your GP needs to have a good understanding of your symptoms in order to make the correct diagnosis, and to give you the most appropriate treatment for your individual situation.

Physical examination

If your GP feels it necessary, they may want to carry out a physical examination to look for signs of any physical conditions that could be causing your symptoms. An overactive thyroid, for example, can sometimes cause similar symptoms to a panic attack. By ruling out any underlying medical conditions, your GP can be sure that they are making the correct diagnosis.

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Treatment

The main aim of treatment for panic disorder is to reduce the amount of panic attacks that you have, and to help ease the severity of your symptoms.

What are the treatment options for panic disorder?

There are two main forms of treatment for panic disorder - psychological therapy and medication. Depending on your individual circumstances, you may require either one of these types of treatment, or a combination of the two.

Before you begin any form of treatment, your GP will discuss all of your options with you, outlining the advantages of each form of treatment, while also making you aware of any possible risks, or side effects. This is because no single treatment is best for everyone, and which treatment is recommended will depend on your general health and the severity of your condition, as well as your personal preferences.

It is important that you understand what your treatment will involve. If you do not understand something your GP has told you, make sure that you ask them to explain it in more detail.

Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) is thought to be one of the most effective forms of treatment for panic disorder.

CBT is a psychological form of treatment, and will involve you having weekly sessions where you talk to a therapist.

For example, they may talk to you about the way you react when you have a panic attack, and what you think about when you are experiencing an attack.

Once you and your therapist have identified negative thoughts and beliefs, you can work on replacing them with more realistic and balanced ones. Your therapist can also teach you ways that you can change your behaviour, which should make it easier for you to deal with future panic attacks. For example, they may be able to show you breathing techniques which can be used to help keep you calm during the stress of a panic attack.

The National Institute for Health and Clinical Excellence (NICE) recommend that you have a total of 7-14 hours of CBT, which is to be completed within a period of four months. Your treatment will normally involve having a 1-2 hour session, once a week.

Self-help techniques

There are a number of self-help techniques that you can use to help treat your symptoms yourself. Some of these techniques are listed below.

During a panic attack

If you are experiencing a panic attack, there are ways you can help ease your symptoms and prevent your attack from getting worse. Some of the ways you can do this are outlined below.

  • Breathe as slowly and deeply as you can - concentrating on your breathing will help give you something to focus on, and will also help to control your physical symptoms.
  • Cup your hands over your mouth and nose while you breathe - this should help to stabilise your breathing.
  • Jog on the spot - jogging has been shown to help to calm some people when they are having a panic attack.
  • Carry a personal object with you - such as a photo of a loved one. This may help if you find that a panic attack is making you feel detached from the situation.
  • Try and focus on something else in your surroundings - this will help to distract you from your panic attack.

Creative visualisation

During a panic attack, lots of things can go through your mind. Some people think about disaster, or even death. Instead of letting your imagination focus on these negative thoughts and images, try and establish some positive visualisations.

Think of a place or a situation that makes you feel peaceful, relaxed, or at ease. Once you know what this image is, you can try to focus your attention on visualising this scene. It should help to distract you from the situation, and in turn may help ease your symptoms.

Try not to fight a panic attack

Fighting a panic attack can often make the experience worse. Trying to fight it and then finding that you are unable to can increase your sense of anxiety and panic.

Instead, during a panic attack, reassure yourself by accepting that although it may seem embarrassing and your symptoms may be difficult to deal with, your attack is not life- threatening. Focus on the fact that your attack will have an end, and try your best to let it pass.

Relaxation

If you have panic disorder, you may feel constantly stressed and anxious, often primarily about when your next panic attack may be. Learning to relax can help to relieve some of this stress and tension, and may also help you to deal more effectively with your panic attacks when they happen.

Some people find complementary therapies, such as massage and aromatherapy, help them to relax. Others find activities such as yoga, or pilates, helpful. You can also practice breathing and relaxation techniques which you can then use during a panic attack to help ease your symptoms.

Exercise

Regular exercise, particularly aerobic exercise, will help you to combat stress and release tension. It can also encourage your brain to release the chemical serotonin, which can help to improve your mood.

You should be aiming to do a minimum of 30 minutes of vigorous exercise, at least five days a week. Vigorous exercise should make you feel out of breath and tired, but not to the point where it is unbearable. Jogging, cycling, and swimming are good examples of moderate exercise.

However, if you have not exercised before, or for a long time, before starting a new exercise programme you should talk to your GP about your current health and fitness level.

Support groups

Support groups will be able to provide you with useful advice about how you can effectively manage your panic disorder, and they are also a good way of meeting other people who have similar experiences of the condition.

Panic attacks can be frightening and isolating, and it can be helpful to know that other people are experiencing the same feelings and emotions.

Support groups often involve face-to-face meetings where you can talk about your difficulties and problems with others. Many support groups can also provide support and guidance over the telephone, or in writing. Ask your GP about local support groups for panic disorder in your area.

Antidepressant medication

Although many people associate antidepressant medicines with depression, they can also be used to treat a number of other psychological conditions. Research has shown that antidepressants can help to prevent panic attacks in more than half of all cases of panic disorder.

Antidepressants can take between 2-4 weeks before they become effective. It is therefore very important to continue taking your antidepressant medication, even if you feel it is not working. You should only stop taking prescribed medication if your GP specifically advises you to do so.

Selective serotonin reuptake inhibitors (SSRIs)

Selective serotonin reuptake inhibitors (SSRIs) are a form of antidepressant which work by increasing the level of a chemical in your brain called serotonin.

SSRIs are the most commonly prescribed form of antidepressant for the treatment of panic disorder. They are normally started at a low dose before gradually being increased as your body adjusts to the medicine. Common side effects of SSRIs include:

  • nausea,
  • low sex drive,
  • blurred vision,
  • diarrhoea, or constipation,
  • dizziness,
  • dry mouth,
  • loss of appetite,
  • sweating,
  • feeling agitated, and
  • insomnia (not being able to sleep).

When you first start taking SSRIs, your feelings of anxiety and panic may seem to get worse. However, in the majority of cases, this is only temporary, and you will usually find that your symptoms start to return to normal levels within a few days of taking the medicine. Speak to your GP if you feel that your symptoms have worsened, and are not showing signs of returning to normal levels after a few days.

When you start taking a SSRI, you should see your GP after two, four, six, and 12 weeks in order to check your progress, and to see if you are responding to the medicine. Not everyone responds well to antidepressant medicines, so it is important that your progress is carefully monitored.

If your GP feels it is necessary, you may require regular blood tests, or blood pressure checks, when taking antidepressant medication. If, after 12 weeks of taking the medication, you do not show any signs of improvement, your GP may try prescribing an alternative SSRI for you to see if that has any effect.

How long will I have to take an SSRI for?

The length of time that you have to take an SSRI will vary, depending on how well you respond to the treatment.

Even if you feel that your panic disorder has been successfully treated, it is likely that you will need to keep taking the medication for at least 6-12 months. If this is the case, and you stop taking your SSRI medication before this time, the risk of your symptoms recurring once you stop taking the medication may be increased. Some people may have to take SSRIs for longer than 6-12 months.

When you and your GP decide that it is appropriate for you to stop taking your SSRI medication, you will gradually be weaned off it, by slowly reducing your dosage. However, you should never stop taking your medication unless your GP specifically advises you to.

Even when taken for a suitable length of time, approximately half of all people whose symptoms have been treated while taking SSRIs find that their panic attacks return once they stop taking the medication.

For some people this means having to take SSRIs on a long-term basis. For others, a course of cognitive behavioural therapy (see below) can help to reduce the risk of your symptoms recurring.

Tricyclic antidepressants

If SSRIs do not help to improve your symptoms, your GP may try prescribing you a different type of antidepressant. Tricyclic antidepressants work in a similar way to SSRIs. They help to regulate the levels of certain chemicals in your brain (noradrenaline and serotonin) which, in turn, helps affect your feelings and mood.

SSRIs are prescribed before tricyclic antidepressants because they have fewer side effects. Common side effects of tricyclic antidepressants include:

  • constipation,
  • difficulty urinating,
  • blurred vision,
  • dry mouth,
  • weight gain,
  • drowsiness,
  • sweating, and
  • lightheadedness.

The two tricyclic antidepressants which are often prescribed to treat panic disorder are imipramine and clomipramine.

Referral

If medication, CBT, or attending a support group do not improve your panic disorder, you may have to be referred to a mental health specialist.

A mental health specialist will carry out an overall re-assessment of your condition. They will ask you about your previous treatment, and how effective you found it. They may also ask you about things in your life that may be affecting your condition, or how much support you get from family and friends. Your specialist will then be able to devise a treatment plan for you, which will aim to effectively treat your symptoms.

The type of mental health specialist that you are referred to will depend on your individual situation. You may be referred to one, or more, of the specialists described below.

  • Psychiatrists train as medical doctors, and then choose to specialise in mental health. A psychiatrist is one of the only mental health specialists who is able to prescribe medication.

  • Clinical psychologists are trained in the scientific study of human behaviour and mental processes. They focus solely on the assessment and treatment of mental health conditions. A clinical psychologist will help you to find ways of effectively managing your anxiety and your panic attacks.
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Complications

Panic disorder is a treatable condition. However, in order to make a good recovery, it is very important that you seek medical assistance as soon as possible. This is because treatment for panic disorder is much more effective if it is given early on.

If left undiagnosed and untreated, panic disorder can become a very debilitating and isolating illness. It can also increase your risk of developing other psychological conditions.

Agoraphobia and other phobias

Agoraphobia is a fear of open spaces. If you have agoraphobia, you may find that leaving home, entering public places, and travelling alone, causes you intense anxiety. Many people who have agoraphobia will avoid normal everyday activities because of their phobia.

Approximately 1 in 3 people with panic disorder go on to develop agoraphobia. People with panic disorder can develop agoraphobia because of their fear of having a panic attack in a public place. You may worry that a panic attack in a public place will be embarrassing, or that you will have difficulty getting help if you need it. You may also worry about public places that you would have difficulty leaving (such as on a train) if you were to have an attack.

If you have agoraphobia, it is likely that you will find it difficult to leave the house, particularly if you are not with a trusted family member, or friend.

If you have panic disorder, you may also develop other fears and phobias, which can often seem irrational. You may start to worry that a particular object, or action, triggers your panic attacks, and so in turn you become fearful of those things.

Children

Panic attacks can also be particularly debilitating for children. A severe case of panic disorder may effect their development and learning. The fear of a panic attack may stop children from going to school and engaging in a social life. They may also find it very difficult to concentrate on their schoolwork.

Drug and alcohol misuse

Some studies have shown that conditions which cause intense anxiety, such as panic disorder, can also increase your risk of developing an alcohol or drug problem.

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