Panic Disorder - Etiology and Prognosis

Panic Disorder - Etiology and Prognosis

Panic is defined as an increased surge in feelings of intense fear. A panic attack typically reaches a peak of panic/fear within a short amount of time. Panic is accompanied by disorienting symptoms like dizziness, shaking, and nausea. When someone experiences this sort of panic multiple times and also finds themselves worrying about future instances of panic or loss of control, they generally meet the diagnostic criteria for panic disorder (PD) (American Psychiatric Association, 2020b). Like all psychological disorders, our primary concern is the extent of how disruptive the presenting symptoms are to the day-to-day functioning of the patient.  

In reviewing the presentation and prognosis of panic disorder (PD), it was interesting to see how simple yet intricate identifying and diagnosing this disorder can be. Unlike many disorders in the DSM that present with psychological symptoms alone, PD can easily be mistaken as a medical condition because of how physical its symptoms can be. This contributes to the fact that PD has a history of being misdiagnosed in medical/hospital settings. Similarly, individuals often do not seek help for PD because of the complex nature of its onset and course of symptoms. This should come as a surprise since PD’s most commonly experienced symptom of the 13 listed in the DSM-5 is a “pounding heart” (Craske et al., 2010), a very physical symptom and experience. 

Given the highly physical symptomatic nature of PD, I wonder when PD was officially determined to be a psychological disorder. Although people with PD often know the trigger of a given panic attack, PD is only diagnosed when someone (also) experiences panic attacks unexpectedly (Craske et al., 2010). I think the fact that PD is defined by unexpected panic attacks without known triggers, and is still considered a psychological disorder rather than a neurological one is noteworthy. 

At present, the etiology of PD is not well understood (Locke et al., 2015). A prominent perspective known as “the neuroanatomical perspective of panic disorder” attributes PD to a genetic-enviornment interaction (Dresler et al., 2012). This hypothesis explains PD as something that emerges from corticolimbic functional abnormalities during emotional processing. Based on this theory, there is a significant biological component to PD but it is at the emotional processing level that the disorder/panic is managed. From this lens, it makes sense that PD is treated as a psychological issue and, as seen in current treatment modalities, there is strong utility in thinking of PD as a multifaceted disorder that can be treated on both neurological (medication) and psychosocial (psychotherapy) levels. 

Together with the mysterious nature of PD with its sudden unexpected attacks, there appears to be a strong relationship between PD and anxiety disorders. Indeed, the assessment often used to identify PD is the GAD-7 (generalized anxiety disorder) screening tool which includes many questions that are applicable to PD (Locke et al., 2015). An example would be the question regarding “feeling afraid as if something awful might happen.” This is a great assessment question for PD given its hallmark symptom of being constantly afraid of future panic attacks. When PD is conceptualized as an anxiety disorder it is much better understood and potentially effective treatment options become much clearer. 

Lifestyle choices appear to play a significant role in the reduction of anxiety and panic attacks. Simple changes to things like caffeine and nicotine intake can improve patient outcomes. Getting good sleep and increasing physical activity are also proven effective measures. Of particular importance is the extent to which the patient feels supported and heard. The establishment of a therapeutic alliance between the patient and physician is important to allay fears of interventions and to progress toward treatment (Locke et al., 2015). The fact that these lifestyle changes can alter the course and severity of PD (and GAD) symptoms seems very indicative of the variables that contribute to the disorder itself ( - where things go wrong in the first place…). Hence, variables related to a person’s quality of life should be taken into account when thinking about PD. This also goes back to the reason that PD is best understood as a psychological disorder - given what we know about the effectiveness of psychological interventions. Group psychotherapy is another great example of this. 

In 2014, a study establishing the effectiveness of cognitive-behavioral group therapy (CBGT) for panic disorder in changing coping strategies was published. It found an overall decrease in panic attacks and anticipatory anxiety in those who completed the 12-session CBGT protocol compared to control in most coping strategies (Wesner et al., 2014). In the case of this study, there was an educational element that addressed effective coping strategies for PD, as well as a social support element that likely emerged from the group therapy modality. The ability of the CBGT to yield results with such clear markers of improvement seems to confirm the hypothesis of PD being an emotional processing issue that can be addressed through adequate psychoeducation and support. 

Panic disorder can be a most debilitating illness if left untreated. Thankfully, there are treatment options for PD that have proven to be effective. Albeit its unpredictable nature and not being fully understood, there is much that is understood about PD that helps direct clinicians in assisting their clients and yielding tangible results. As a whole, increasing one’s quality of life on a personal and interpersonal level is key to successful outcomes for PD. Studying what helps alleviate symptoms of PD is important because it can help understand the etiology and prognosis of the disorder. It is not necessary to be stuck at home in fear of panic attacks and an often scary unknown. Reaching out and being open to change can go a long way in attaining health and freedom to proceed into a better future.

Bibliography 

American Psychiatric Association. (2020b). Desk Reference to the Diagnostic Criteria from DSM-5. Independently published.

Craske, M. G., Kircanski, K., Epstein, A., Wittchen, H. U., Pine, D. S., Lewis-Fernández, R., & Hinton, D. (2010). Panic disorder: a review of DSM-IV panic disorder and proposals for DSM-V. Depression and Anxiety, 27(2), 93–112. https://doi.org/10.1002/da.20654

Dresler, T., Guhn, A., Tupak, S. V., Ehlis, A. C., Herrmann, M. J., Fallgatter, A. J., Deckert, J., & Domschke, K. (2012). Revise the revised? New dimensions of the neuroanatomical hypothesis of panic disorder. Journal of Neural Transmission, 120(1), 3–29. https://doi.org/10.1007/s00702-012-0811-1

Locke, A., Kirst, N., & Shultz, C. G. (2015). Diagnosis and management of generalized anxiety disorder and panic disorder in adults. American Family Physician, 91(9), 617–624.

Wesner, A. C., Gomes, J. B., Detzel, T., Blaya, C., Manfro, G. G., & Heldt, E. (2014). Effect of cognitive-behavioral group therapy for panic disorder in changing coping strategies. Comprehensive Psychiatry, 55(1), 87–92. https://doi.org/10.1016/j.comppsych.2013.06.008