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Panic Disorder

What is a panic attack? What is panic disorder?

A panic attack is a brief episode of intense fear. It is accompanied by multiple physical and cognitive symptoms that occur repeatedly and unexpectedly in the absence of any external threat. People with panic disorder experience recurrent and unexpected panic attacks and persistent fears of repeated attacks. People are diagnosed as having a panic disorder if they have had four attacks within a four week period, or following one or more attacks, have the persistent fear of having another attack. Anticipatory fears of having panic attacks in public places, or where no help or escape seems possible may lead to the individual becoming housebound and the development of agoraphobia.

While panic attacks are common, with up to 30 per cent of the population experiencing a panic attack during a given year, panic disorder is less common, affecting 2 to 3 percent of the population.

Symptoms

A panic attack includes four or more of the following symptoms:

Understanding the development of panic disorder

The fight-flight response

The body's physical responses to danger or a perceived threat is known as the 'fight-flight response'. As this term indicates, the body's response is aimed to prepare the individual for immediate action - either to fight or flee the danger. In other words, it is a protective mechanism - a response to ensure survival of the species. The evolutionary development of the fight-flight response over thousands of years, has ensured that it has become an automatic response to danger - hard-wired into our autonomic nervous system. When a danger or threat is perceived, the brain activates the autonomic nervous system, which controls physical activities that occur automatically - such as breathing. The autonomic nervous system has two branches - called the sympathetic nervous system and the parasympathetic nervous system. The sympathetic nervous system controls the 'fight-flight response' and the parasympathetic nervous system regulates functions which restore the body to a normal state. The sympathetic nervous system activates a range of complex reactions when a danger or threat is perceived. Firstly all non-essential activities are suspended and several chemicals are released - in particular, adrenalin and noradrenalin. A number of physical changes are triggered that enable immediate and fast action to occur. These changes include the following (extract from "Anxiety, Phobias and Panic: A Step by Step Program for Regaining Control of Your Life", by Reneau Z. Peurifoy, 1995):

These physical responses ensure an immediate response to danger. An individual can instantly respond by fighting or fleeing, and their body's automatic responses provide strength and stamina for a greater possibility of survival.

It is important to note that the sympathetic nervous system responds automatically to the brain's alarm system - which is triggered by an individual's perception of danger. The physical reactions will be the same, and of similar intensity, regardless of the level of danger. Also once the sympathetic nervous system is activated, and adrenalin is released, the physical responses that occur will continue for some time - even if the danger quickly passes. Sympathetic nervous system activity is terminated in two ways: first, the chemicals adrenalin and noradrenalin are eventually destroyed by other chemicals in the body. Second, the parasympathetic nervous system becomes activated and restores the body to its normal resting state. These two physical responses aimed at nullifying the flight-fight response are also automatic - they will occur. In other words, physical anxiety responses cannot keep rising forever, or escalate to damaging levels. The parasympathetic nervous system is a built-in safety valve, that stops activation of the sympathetic nervous system from continuing beyond levels that are safe for the body. The body's own inherent 'calming' response can take some time - hence the feelings of apprehension and tension that may linger for a much longer period of time than the actual experience of danger. It is also common to feel exhausted and drained as an after effect of the sympathetic nervous system's responses, as the whole process requires significant energy.

Modern day fears: the perception of threat and anxiety

External dangers still occur, but are less common on a daily basis for most people than was the case for our ancestors. More commonly today, the perception of threat is associated with matters of a psychological, emotional and social nature - for example, loss of a significant relationship, loss of capacity or ability to perform various roles, and loss of social status, possessions or economic status. These types of 'threat' give rise to the more vague and ill-defined sense of impending danger that we term anxiety. In general, the sympathetic and parasympathetic systems effectively regulate the body's responses to periodic levels of mild anxiety and stress, so that occasional 'fight-flight' reactions are effectively moderated and receive only passing attention from the individual. Also if the perceived threat - though of a psychological, emotional or social nature, is recognised and acknowledged as a significant danger to a person's well-being - for example, if a partner left home issuing threats of divorce, if a stock market crash resulted in major financial loss, if on-going bullying at school or work resulted in low esteem and poor performance - then any physical reactions to such stresses would be generally accepted as normal under the circumstances.

The first panic attack

When the physical symptoms of the 'fight-flight' response are triggered for no apparent reason - an individual will begin to experience a heightened sense of threat, and subsequent anxiety, as all the body's 'alarm bells' are ringing and yet the danger appears to be hidden - like hearing noises in your home at night that sound like there might be intruders but not knowing if they are there or where they might be. The individual's heightened sense of alertness and vigilance for danger, having been unsuccessful in finding the threat in the environment, turns then to the body - and scans the body for the source of threat. At this stage, with sensations racing through the body which indicate danger, and surging emotions of distress and fear, a wave of anxious thoughts begin to rise as the person seeks to make sense of what is happening to them. The most common type of thoughts that occur at this time are cognitive interpretations of the physical flight-flight responses:

Such thoughts intensify emotional distress and anxiety, the brain's 'alarm bell' signals an emergency situation, and more adrenalin is released to increase the body's capacity to fight or flee the danger - the heart beats faster, breathing quickens and becomes more shallow, sensations of dizziness and nausea increase. The individual is now experiencing their first panic attack.

The cycle of physical symptoms and emotional and cognitive reactions described above, providing an explanation of the onset of a panic attack, has been verified through extensive research. This research has demonstrated that people with panic attacks are fearful of the actual physical sensations of the flight-fight response, and fear and panic escalate when an obvious explanation cannot be found and the source of the danger is perceived to be the person's own body. This leads to a misinterpretation of the physical symptoms of the flight-fight response as indicating some serious or life-threatening mental or emotional problem.

Possible precursors to the first panic attack

While the cycle of physical, emotional and cognitive responses that comprise the panic attack can be readily understood, the onset of the physical symptoms of the flight-fight response in the first place seems more difficult to comprehend. The obvious question is - why is the flight-fight response triggered if there is no obvious source of danger?

In fact, there are many ways in which the fight-flight response, or physical reactions associated with this response, can be triggered other than by danger and fear, including:

Following the first panic attack, many people go to a doctor to seek an explanation for their frightening symptoms. In fact, it is recommended as a first step in dealing with panic attacks that a doctor is consulted to determine if any of the physical symptoms are a result of a medical condition, or the taking of any medications or drugs. When medical causes are ruled out, the person may initially experience some relief, and the doctor may offer possible alternatives for the cause of the symptoms, including stress or changes in physical activity or environment. Many people would find the explanations offered acceptable and think little more about the incident - in fact, up to 30% of the population have a panic attack at some time in their life. For others, however, the initial relief is short-lived, and the experience of the panic attack, combined with other factors - such as particular personality traits and current stresses, may lead to an ongoing preoccupation with the experience of the panic attack.

The development of panic disorder

Rising apprehension about the possibility of another similar experience occurring and all the imagined consequences - such as fainting and losing control in public, leads to higher levels of anxiety being experienced on a daily basis, and efforts made by the person to prevent the possibility of another attack occurring. At this time, any physical sensations become a source of concern, and regular scanning of the body occurs to check for possible recurrence of the symptoms of the attack. This combination of anticipatory anxiety, lack of a satisfactory explanation for the symptoms, and a heightened vigilance for bodily sensations leads directly to the development of recurring panic attacks and panic disorder.

For some people, panic attacks ignite strong feelings of vulnerability, and concerns about the possibility of experiencing panic in a place where they may not be able to escape, or would be subject to public scrutiny, or where they could not obtain immediate help, become a dominating fear. In order to protect themselves from what they perceive to be catastrophic consequences should these situations occur, these people begin to modify their behaviour and activities to try to ensure that they will always feel safe. What are commonly termed 'safety behaviours' often include:

Safety behaviours such as these reinforce the person's feeling of vulnerability and fear of panic attacks, as the person comes to define more and more areas of the world, their life and their own body as dangerous and their own capacity to cope as weak and ineffectual. If the panic and anxiety cycle combine with increasing safety behaviours, agoraphobia may develop and for some, simply walking out through their own front door may be a nightmare that seems impossible to bear.

Treatment of Panic Disorder

Cognitive behavioural therapy is a psychological treatment for panic disorder and agoraphobia which has substantial clinical and research evidence that supports its effectiveness. A range of anxiety management techniques are generally included in psychological treatment approaches to assist people's ability to manage their own symptoms. Anxiety management techniques include relaxation training, meditation, slow breathing techniques, coping statements and hyperventilation control. These techniques require regular and consistent practice to be of benefit, and are most effective if used in conjunction with a cognitive behavioural treatment program. There are a number of self-help books available which provide information about the use of these strategies and self-help programs.

More information on the psychological treatment of panic disorder

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