Panic Disorder: Causes and Treatment

Anxiety disorders are a common malady among many populations. Panic disorder is one of the more common forms of anxiety disorder, affecting millions of people worldwide. In Europe, 2-3% of the population is affected by the disorder every year (Taylor, 2006) . Overall, the preference is 2.1%-4.7% (Kim, 2019) . Because of its potential to cause significant individual and social malfunctioning, the disorder merits scholarly attention. This paper characterizes the disorder, with focus on its symptomatology, diagnosis, treatment, effects on individuals and families as well as its cultural relevance. 

Overview 

Panic disorder is characterised by episodes of intense fear that is unprovoked, or not related to any real physical danger, that are often accompanied by physical symptoms in the individual to an extent that their normal functioning is impaired. While some individuals may experience only a few of these episodes in a year, others may experience several attacks in a day. The severity of the disease is, therefore, related to the frequency of the attacks, intensity and the impact that these have on the individuals. Those with severe attacks have been shown to need more medical care, have less productivity at the workplace and enjoy a lower quality of life. Comorbid mental conditions such as suicidal tendencies are also more common in this group (Jonge et al, 2016). 

Major Symptomatology 

To understand the symptomatology of a panic disorder is to discern what a panic attack is. According to the DSM-5 criteria, one must have at least four of the identified symptoms to be said to have a panic attack. Among these are: sweating, shaking, a feeling of choking, palpitations, chest pain, shortness of breath, light headedness or dizziness, fear of dying, chills, the fear of losing control among others (Kim, 2019) . A person that has panic disorder will have at least four of these symptoms, followed by a period of at least one month of worry about possible recurrence, and maladaptive behaviour as a consequence of the attack. It is also important that this pattern is not a result of physiological or physical substances, or other mental disorders such as compulsive obsessive disorder. 

Etiology 

Several factors are thought to contribute towards the development of panic disorder. Genetic makeup, the biological factors of an individual, as well as environmental factors are thought to have a bearing on the development of some individuals and not others. What is not known though, is the specific model for the interaction of these factors, and their weights in the influencing of the development of the disorder. It is not clear, therefore, whether physical relations and other stressors are additive with genetic predisposition or merely contributory towards the increasing risk of development of the disorder in the susceptible individual. 

There is evidence to suggest a genetic basis for panic disorder. While no specific gene locus has been established for the development of the disorder, racial and ethnic trends suggest that the disorder could have a genetic predisposition. In addition, it has been suggested that there are genome-wide associations for panic disorder (Na, Kang, Lee & Yu, 2011), making the possibility of pinning down a specific gene locus for the disorder a far cry from the currently available diagnostic capabilities. People with other comorbid conditions which have been shown to have genetic predisposition have also been shown to carry a higher risk for the development of the disorder, pointing further to the possibility of a genetic basis for the disease. 

Environmental factors that contribute to the development of panic disorder include poor socio-economic status of the individual, separation from family either through death of parents or divorce and being of single marital status (Noyes et al, 1993). A highly stressful environment and stressful events have also been shown to be precipitants of panic disorder. Such events as a sexual abuse, trauma resulting from other environmental variables and grief due to loss of whatever kind are examples of environmental factors that can lead to the development of panic disorder and other anxiety disorders (Hetema et al, 2005). 

As with the other anxiety disorders, having one form or the other of anxiety disorders is a risk factor for the development of panic disorder. Comorbidity is, therefore, an important contributor and predictor of the probability of development of panic disorder. 

Biological factors that contribute to the development of panic disorder include an abnormality in certain neurotransmitters. Serotonin, GABA and Noradrenaline have variously been shown to have a role in the development and perpetuation of panic disorder (Erikson, 1987) . A low level of serotonin, low GABA level and high noradrenaline levels have been suggested as culprits in the neuro-mechanism for the development of panic disorder. There are studies, however, which contend the theory of serotonin as a precipitant, implying that there is no role for the neurotransmitter in the development of the disorder (Charney & Heninger, 1986). 

Affected Populations 

There is a huge heterogeneity in the occurrence of panic disorders. These variations are postulated to be due to different methodologies applied in the research of the disorders rather than a function of the variable cultures (Bandelow & Michaelis, 2015). The prevelance is similar in across races and there is no significant age differences except an tendance to decline with increasing age. 

Women are more likely to be affected than men, with a 2-3 fold likelihood comparatively. The black populations are more likely to present with somatic symptoms as opposed to psychological manifestations alone, and are more likely to seek medical as opposed to psychiatric help (Levine, 2014) . A high index of suspicion must, therefore, be maintained particularly with such patients presenting with non-specific physical symptoms so as not to miss the diagnosis of panic disorder . 

Culture, Diversity and Social Justice 

There has been quite a contention in academic circles as to whether or not culture has a bearing on the ocurrence of panic disorder. It is widely agreed, however, that culture exerts its impetus on the evolution of this disorder in terms of its influence on the environmental factors that then affect the disorder. The ethnopsychology of disease offers that the mode of formation and expression of emotions in individuals is not without the influence of the belief systems that are dominant in any given geographical or funcional area. 

The perception and acceptance of certain symptoms, for instance, varies across cultural realms. The black population is less likely to accept the symptoms of the anxiety disorders compared to their white counterparts (Hofmann & Hinton, 2014). Such acceptance can, therefore, be defined as a funnction of the cultural definitions of what is ‘right’ or acceptable model of behavior, so that the definition of such disorders is inextricably entangled with the cultural campus of any given area. Understanding the cultural influence on panic disorder is thus a necessity rather than a luxury, in the quest to pursue a deeper comprehension of the wider biopsychosocial model for the disease. 

The development and perception of the wider spectrum of anxiety disorders is also inevitably characterised by cultural undertones. For instance, whereas one cultural context may indentify snakes as a dangerous reptile that should be avoided by all means, the snakes may very well be a highly sought after delicacy in another cultural context. It is for this reason that contextualization of anxiety disorders in general and panic disorders in particular cannot escape consideration of the cultural reality of individuals. 

The questiont that arises though, is whether such cultural awareness should also warrant a change in the definition of what qualifies to be an anxiety disorder across different cultures to retain cognizance of the variations in cultural perceptions of the disorder. While developing such specific definitions may not only be difficult but also confounding to the psychiatrist, the universalized definitions cannot rid themselves of the awareness of cultural effect. 

Differential Diagnostic Considerations 

There is a significant overlap in the symptomatology of panic disorder in relation to other anxiety disorders and mental disorders in general. This is the reason as to why it is absolutely important to rule out other conditions before a diagnosis of panic disorder can be courted with confidence. Unfortunately, many psychiatric disorders have panic attack-like symptoms as the basis for their definitions, confounding the diagnosis of the disorder and inviting a consideration of many differential diagnoses in the evaluation of the disorder. 

Depressive disorders, post traumatic stress disorder, substannce abuse disorders, schizophrenia, bipolar disorder as well as other anxiety disorders are to be considered. Medical disorders such as angina pectoris, pulmonary embolism, cardiac dysrythmias, transcient ischemic attacks, hypoglycemia episodes, hypothyroidism among other illnesses that can present with the said symptomatology should also be considered and duly ruled out. 

It is particularly important to rule out medical issues because of their urgent nature. Angina pectoris, for instance, in a patient presenting with chest pains, difficulty in breathing, light headedness, fear of impending doom among other symptoms, that are similar to those seen in panic attacks, portends devastating consequences if missed. The same can be said about hypoglycemia, which potentially leads to death if missed, severe hypothyroidism and the typical myxedema coma, electrolyte imbalance and other disorders that have the potential to lead to quick death. Investigations in suspected cases must therefore maintain cognizance of this, and rule them out as a matter of necessity (Tully et al, 2015). 

The psychiatric differentials are equally important, and it is only through their proper identification that proper treatment can be instituted. Post traumatic stress disorder, for instance, can present with features with semblance to panic attacks, such as intense fear, palipitations, reliving of a certain traumatic event, fear of, and avoidance of certain stimuli and others that can easily be mistaken for panic disorder. 

Depressive states can also mimick panic attacks. Symptoms such as palpitations, shortness of breath, chest pains, light headedness and others are also commonplace and make it difficult to distinguish from panic disorder. Other disorders such as somatization disorder, substance abuse and generalized anxiety disorder, as well as agoraphobia easily manifest in symptoms similar to those exhibited by panic disorder. 

Assessment 

The assessment of panic disorder poses two huge huddles. Firstly, because a panic attack typically comes out of the blue, it is difficult to exhibit it and instead the clinician has to rely on the self-report of the patient. Secondly these reports are subjective, making their exact identification reliant on the patient rather than on any form of objective scales. This makes it important to look at the wider panic disorder rather than focus merely on the panic attack. It is for this reason that the consideration of the chronic feeling and fear of impending attacks, and the exclusion of other possible disorders is critical. 

The assessment of the patient, therefore, includes a detailed history, including a probe into the childhood and development of the patient. A mental status examination as well as a thorough medical examination is important to rule out medical disorders. There cannot be susbstitutes for a proper clinical examination of the patient as well as baseline investigations that would include a complete blood count, blood electrolytes, blood glucose, thyroid function tests, liver function tests and other tests as may be dictated by the predominant symptoms of the patient. A diagnosis will then be formulated based on these features. 

It is important to consider a holistic approach to the assessment of the patient, so as to reduce the risk of misdiagnosis and the uwanted consequences that come with it. Because medical conditions present a critical dimension to the management of the patient, the importance of characterizing them when present and treating appropriately cannot be overstated. Their occurrence does not, however, preclude the occurrence of co-existing psychiatric illness, making a case for the need to be careful while treating such patients. 

Treatments 

The management of panic disorder encompasses the general aims of reducing the panic attacks, managing or eliminating the anticipatory anxiety that may be present, managing other disorders that may be occuring alongside the primary disorder, attaining remission and reverting back to the pre morbid functioning of the patient. Several approaches can be taken, and these include pharmacologic as well as psychological treatments. A meta-analysis showed that none was superior to the other (Zulfarina, 2019) . There is no consensus as to when to start treatment for the disease, with some schools of thought offering that treatment should be reserved only for those with symptoms that impair functionality while others postulate that any treatment should begin immediately. 

Pharmacological management 

Several drugs have been known to have efficacy against panic disorder. For many years, benzodiazepiines, selective serotonin reuptake inhibitors, calcium channel blockers and others have been used to control panic attacks. The reservation with pharmacological management however, has been the low compliance rates for the patients, and low efficacy (Zulfarina, 2019) . Effort has been channeled into the development of a novel product with higher efficacy and less side effects compared with the conventional medications, but the process is likely to take long. 

Medications, however, have the disadvantage of high costs, non-compliance, high levels of side effects as well as low efficacy. When there are comorbid conditions, the use of certain medications may portend worsening of the other conditions, complicating the outcomes of such tretments on the individuals. The shift to psychotherapy carries the advantage of avoiding such unwanted interactions for the patieint. 

Psychotherapy 

Cognitive behavioral therapy has emerged as a treatment of choice for the disorder. The advantage that such an approach wields is that the likelyhood of non-compliance is reduced, while the patient is also able to avoid the side effects that are related to the intake of many drugs. The approach has the advantage of involving the patient in their own management as well as good efficacy. In the long run, the approach has been shown to be less costly compared to the pharmacologic option ( Manjula, 2009). 

A combination of pharmacotherapy and cognitive behavioral therapy has been shown to have better outcomes than either of the two in isolation. Patients that exhibit severe symptoms may warrant in-patient management. Those that are considered harmful or violent, or likely to commit suicide, are candidates for hospitalization until such a time as may be cinsidered safe for them to be managed as outpatients. 

Effects on Family and Caregivers 

A wide range of effects of panic disorder on family members and caregivers can be conceptualized. The burden of disease on family members and caregivers is not only related to the cost of treatment, but by the effect of the severed social relations and social status that comes with the disorder. Because the social functioning of the individual is disrupted, the family members have to incur not only time expenses, but also psychological stress from being in such a situation. If the affected individual had a family and children, then these too have to be taken care of by the family members, which is an additional cost to the caregivers and succeeding family members (Detzel, 2014) . 

Because of the symptomatology of the disorder, the patient is also often at a loss when it comes to social function. The relationships with the family members may deteriorate, making it even more difficult to cope with a the situation. The psychological burden of having a family member with a psychiatric disorder is not any less than the other burdens described. The presence of other comorbid disorders also exert additional pressure on the family members, with the psychological turmoil that accompanies such diagnoses not the least concern of such families. If such a disorder leads to complete disfunction of the individual, with resultant divorce, suicide or other outcomes, the family is inevitably affected either on pure psychological basis or because of having to shoulder whatever consequences result from the disfunction. 

Conclusion 

Panic disorder is among the most common anxiety disorders, affecting as many as 3.5 percent of the world’s population. Presence of panic attacks, fear of impending attacks and the absence of other mental disorders or medical conditions define a panic disorder. Cultural differences exist in the acceptance of symptoms and health seeking behaviors, as well as contextualization of the disorder. Management of the disorder can be achieved either through pharmacotherapy with the use of benzodiazepines and other medications or through the application of cognitive behavioral therapy. Cognitive behavioral therapy has emerged as a useful tool in the management of the disorder, preferred because of low levels of non-compliance, lower cost in the long-run as well as high efficacy of treatment. The disorder exerts a huge burden not only to the individual but also the family members and caregivers. 

References  

Borwin Bandelow, S. M. (2015). Epidemiology of anxiety disorders in the 21st century. Dialogues in Clinical Neuroscience , 327-335. 

Dennis Charney, G. H. (1986). Serotonin Function in Panic Disorders The Effect of Intravenous Tryptophan in Healthy Subjects and Patients With Panic Disorder Before and During Alprazolam Treatment. JAMA Psychiatry . 

Detzel, T. (2014). Family burden and family environment: Comparison between patients with panic disorder and with clinical diseases. Psychiatry and clinical neurosciences . 

Erikson, E. (1987). Brain neurotransmission in panic disorder. Acta Psychiatrica Scandinavica Supplemenum , 31-37. 

Hae Ran Na, E. H. (2011). The Genetic Basis of Panic Disorder. Journal of Korean Medical Science , 701-710. 

John Hetema, C. P. (2005). The Structure of Genetic and Environmental Risk Factors for Anxiety Disorders in Men and Women. JAMA Psychiatry , 182-189. 

Jonge, P. D. (2016). Cross-national Epidemiology of Panic Disorder and Panic Attacks in the World Mental Health Surveys. Depress Anxiety , 1155-1177. 

Kim, Y. K. (2019). Panic Disorder: Current Research and Management Approaches. Psychiatry Investigations , 1-3. 

Levine, D. S. (2014). Panic disorder among African Americans, Caribbean blacks and non-Hispanic whites. Social Psychiatry and Psychiatric epidemiology . 

M. Manjula, V. K. (2009). Cognitive behavior therapy in the treatment of panic disorder. Indian Journal of Psychiatry , 108-116. 

Philip J Tully, G. W. (2015). Panic disorder and incident coronary heart disease: a systematic review and meta-analysis protocol. Systematic Reviews . 

R Noyes, J. C. (1993). Environmental factors related to the outcome of panic disorder. A seven-year follow-up study. The Journal of Nervous and Mental Disorders , 529-538. 

Stefan Hofmann, D. H. (2014). Cross-Cultural Aspects of Anxiety Disorders. Current Psychiatry Reports . 

Taylor, B. C. (2006). Panic Disorder. British Medical Journal , 951-955. 

Zulfarina, M. (2019). Pharmacological Therapy in Panic Disorder: Current Guidelines and Novel Drugs Discovery for Treatment-resistant Patient. Clinical psychopharmacology and neuroscience .