What is panic disorder? What to do if you have a fear of recurring panic attacks

Hannah RobertsMay 27, 2020, 04:19 IST

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Recurring and unexpected panic attacks can lead to panic disorder.Tero Vesalainen/Shutterstock

Panic disorder is an excessive fear of recurring panic attacks.
The symptoms of panic disorder also include a noticeable change in behavior to avoid situations that relate to the attack — for example, this can be staying inside your home as much as possible.
To treat panic disorder, cognitive behavioral therapy paired with medication and lifestyle changes has proven to be effective.
This article was medically reviewed by David A. Merrill, MD, PhD, psychiatrist and director of the Pacific Brain Health Center at Pacific Neuroscience Institute at Providence Saint John's Health Center.

Panic disorder is a type of anxiety disorder that is characterized by an excessive fear of recurring panic attacks. An estimated 4.8% of Americans are affected by this anxiety disorder in their lifetime.

If you have a panic attack, that doesn't mean you have panic disorder. Panic attacks and panic disorder are classified as separate entities in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

In fact, panic attacks are much more common. About 23% of Americans will have a panic attack in their lifetime. But many people who experience one will not have another episode.

If you have two or more two or more panic attacks, and start to avoid situations or places where you think another one might occur, you may have panic disorder.

Here's what you need to know about the symptoms of panic disorder, how to know if you have it, and what you can do for treatment.

What are the symptoms of panic disorder?

Panic disorder is when someone experiences regular and unexpected panic attacks — with no apparent cause or trigger — and lives in fear of another panic attack occurring.

"The symptoms of panic disorder can be a real intense fear and apprehension that seemingly come from nowhere," says Ahmet Mehmet, a psychotherapist who works with anxiety disorders.

As a result, people with panic disorder avoid situations or places where they suspect a panic attack might occur. Sometimes, panic disorder occurs with agoraphobia, another type of anxiety disorder that involves fear of being outside the home alone in certain places.

While the DSM-5 does not specify how regularly the attacks have to happen in order to be diagnosed with panic disorder, it does say:

At least one attack is followed by at least one month of concern about having another attack, and the implications
There is a significant change in behavior to avoid situations that relate to the attack

Panic attack symptoms

Panic attacks are a brief, sudden onset of intense fear or discomfort that reach a peak within 10 minutes or less before beginning to subside.

According to the Anxiety and Depression Association of America (ADAA), there are 13 types of physical and emotional panic attack symptoms. The major symptoms are:

Palpitations or a rapid heart rate
Trembling or shaking
Shortness of breath
Feeling dizzy, unsteady, light-headed, or faint
Fear of losing control
Fear of dying

It can also be important to know the difference between a panic attack and an anxiety attack, which have similar symptoms but vary in their triggers.

What causes panic disorder?

There are a few different theories that help explain the causes of panic disorder.

One established theory claims that genetics plays a key role, suggesting that patients inherit a sensitive central nervous system fear mechanism, centered in the amygdala — the part of the brain involved with experiencing emotions — and this overactive mechanism brings about fearful responses and panic attacks.

"Panic disorder is partially influenced by heightened activity in parts of the brain known as the hypothalamus and amygdala," says Mehmet. The hypothalamus contains the parts of the brain that are activated when we feel fear. In patients with panic disorder, this fear network is hypersensitive.

Additionally, the cognitive model of panic suggests that panic disorder and panic attacks represent a fear of fear. For example, if you fear the physical symptoms associated with anxiety, your body will further escalate that anxiety and increase arousal of the sympathetic nervous system, inducing a fight or flight response and resulting in a panic attack.

Several studies show that early life stressors — known as adverse childhood experiences (ACEs) — can also increase the risk of panic disorder.

These stressors include:

Sexual abuse
Physical or verbal abuse
Early parental loss
Growing up in a low-income household

Panic disorder treatment

The best way to treat panic disorder is through a combination of cognitive behavioral therapy (CBT), antidepressant medication, and lifestyle changes.

Therapy

Cognitive behavioral therapy (CBT) is considered a first-line of treatment for panic disorder. Through CBT, patients are encouraged to experience or encounter their feared situations and sensations under safe conditions.

With the help of a clinician, patients then learn a set of strategies to counter fears of panic attacks and break the recurring cycle of anticipatory anxiety and panic. Examples of these strategies include:

Refocusing your thoughts. When negative or anxious thoughts begin, you can learn how to intentionally interrupt them and consciously focus on positive scenarios.
Guided imagery. This process involves closing your eyes and visualizing imagery that helps you feel calm and relaxed.

CBT has been shown to be one of the best treatments for panic disorder, proving effective for about 77% of patients.

Lifestyle changes

In addition, patients are encouraged to make a few key lifestyle changes to better manage their symptoms. These include:

Breathing training. Slow breathing techniques have been shown to reduce panic symptoms and the hyperventilation which accompanies panic attacks. This is where patients are taught to breathe slower, deeper, and more regularly. It's a core feature of most psychological treatments for panic disorder.
Mindfulness meditation. Mindfulness, or the quality of being present and fully engaged with your body and your surroundings, can reduce stress and help you overcome feelings of uncertainty or lack of control. Here's how to meditate on your own.
Diet. Excessive caffeine intake can contribute to the development of panic disorder, says Mehmet. Patients should avoid all substances that can exacerbate anxiety, such as alcohol, drug use, and unhealthy foods like processed meat, soda, and fruit juice.
Exercise. This is often recommended to expose patients to increased heart rate and shortness of breath — the symptoms of panic — to help them face what they are afraid of to reduce fear. And regular exercise is also proven to reduce stress and help some people manage anxiety disorders.

Medication

Medication may be given upon diagnosis of panic disorder, according to Mehmet. Selective Serotonin Reuptake Inhibitors (SSRIs), like Zoloft and Paxil, are considered the first-line treatment option for patients with panic disorder.

These work by boosting levels of serotonin in the brain, the neurotransmitter associated with contentment and lower levels of anxiety.

Other antidepressants clinically proven to be effective in treating panic disorder include:

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs): SNRIs, which include Cymbalta and Effexor, function similarly to SSRIs, except they also increase levels of norepinephrine, a neurotransmitter that helps the body respond to stress.
Tricyclic Antidepressants (TCAs). This type of medication increases levels of norepinephrine and serotonin. However, they're an older class of drugs and are generally only used if SSRIs and SNRIs fail, because they may have more severe side effects, including sudden drops in blood pressure.
Monoamine Oxidase Inhibitors (MAOIs). MAOIs work by blocking the monoamine oxidase enzyme. This enzyme is involved in removing the neurotransmitters norepinephrine, serotonin, and dopamine from the brain.

In patients with coexisting conditions or when symptoms are severe, it is common that a benzodiazepine — such as Xanax or valium — is used until the antidepressants take effect.

Benzodiazepines are a type of psychoactive drug with sedative and muscle relaxant properties that calm the symptoms associated with anxiety. They act on the neurotransmitter gamma-aminobutyric acid (GABA), which helps calm the nervous system.

They're often taken as-needed or on a short-term basis to relieve anxiety episodes, as they can cause dependency if used long-term. Benzodiazepines may also block memory formation in the brain, making it more difficult to benefit from CBT while on this type of medication.

The bottom line

While panic disorder likely won't be cured, symptoms can be managed effectively where they no longer have such an influence over an individual's life.

If you're experiencing recurring panic attacks that affect your quality of life, talk with your doctor about the treatment methods that are best for you.

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