Panic Disorder Essay, Research Paper
The defining characteristics of panic disorder as given by the American Psychiatric Association consist of the following four criterions:
The person has experienced repeated unexpected episodes of panic attacks.
At least one of these panic attacks must have been followed by persistent worries lasting approximately a month or more regarding the fear of the consequences of the attack, or a specific change in the person’s lifestyle due to the experience.
During the attacks the minimum of four of the following sensations or symptoms must be experienced:
shortness of breath
trembling or shaking
increased heart rate
chest pain or discomfort
feeling that the surroundings are not quite real
fear of going crazy
fear of dying
Drugs or a medical condition must not have induced these attacks.
The American Psychiatric Association first officially recognized panic disorder with the publication of Diagnostic and Statistical Manual of Mental Disorders (3rd edition) in 1980.The mental handicap of panic disorder afflicts roughly 1 of 75 people worldwide at any point during their lives. Panic attacks experienced by those with panic disorder last approximately 10 minutes.
Panic attacks are a result of anxiety or fear and subsequent attacks may be induced by the fear of panicking itself. This fear is conducive to bringing about increases the person’s fear of undergoing an attack. Afterwards, the victim may escape the situation thus allowing decreasing the sense of fear thus begins the process of depleting panic attack symptoms they had experienced. This process is labeled by some as the panic attack spiral.
Due to the fact that people who are plagued by panic disorder tend to associate the cause of their illness with a specific place or situation the first attack had occurred in, some may develop agoraphobia. They feel as though they may lose control of their bodies accompanied by an intense fear of a panic attack occurring. Some may discontinue their use of public transportation, or going to shop at the supermarket. It may progress to a point where they can no longer leave their homes. They tend to avoid situations or places in which they feel a panic attack may reoccur.
As shown in the panic spiral diagram, those who suffer from panic attacks feel the urge to escape the situation in which they had experienced the first panic attack because they feel being in the same or similar situation may induce another attack. In this manner the victim may began avoiding situations identical or similar to the place of the first attack. In this manner the victims may develop agoraphobia as a by-product of suffering from panic disorder.
For approximately one-third of cases reported, the initial attack had taken place in a public environment, one-third in their own homes, and approximately a quarter had taken place in a car. Generally, there is a link between the first panic attack and a source of major stress the person may have been bearing the burden of at the time of the attack. However, many at first are under the misconception that they are suffering from a medical condition. For example those who feel chest discomfort during these attacks may believe they are having a heart attack or other similar medical condition. Then when it is confirmed they have no such medical condition, yet they continue to have attacks, soon thereafter they feel as though it is beyond their control.
Subsequent attacks are often situational panic attacks, this is a type of attack induced by a form of perceived external threat to the victim such as being in a situation in which an attack had previously occurred. Anticipation of such an attack may also lead to another episode of panic attack because it increases the person’s level of anxiety.
There are also nocturnal panic attacks which occasionally effects the victim during their sleep. Then person usually awakens to a panic attack. These attacks posses the same symptoms as daytime attacks, however nocturnal attacks on average last approximately 25 minutes as opposed to the average of 10 minutes for daytime attacks. Nocturnal attacks do not seem to have a correlation to bad dreams or nightmares, and during these attacks the victims are conscious and responsive and if need be are able to recall the experience.
Several cases have been reported of relaxation-induced panic attacks. It is possible that while they are attempting to relax they are focusing on specific bodily sensations. There are those who believe that being in a state of relaxation debilitates normal blocks to thoughts which make the victim anxious. These cases are thought to be brought on by the fear of losing control. Such as being unable to take certain medications of relaxation for fear of being unable to control oneself as in the case of Ann in case study A who refused the offered general anesthetic and instead wished to have a local anesthetic for her biopsy. She had the fear of, just letting go”.
The most perplexing and hardest to explain of all types of panic attacks are those which are unexpected. For lack of a better explanation, there is a belief that the symptoms are caused by a sense of danger triggered by a signal of internal threat. These panics because of their unpredictable nature add another dimension of threat consisting of the fear that the victim is not safe anywhere.
The aftermath of panic attacks are grave, 3 phases of stress buildup have been identified among those who suffer from panic disorder. The first phase is known as the flight phase or the fight response phase. This is the phase in which the victim’s body sends a signal to the brain suggesting alarm. Consequently, the brain responds by releasing hormones, which aid in coping with stress. In doing so, the heart begins to hasten and perspiration may occur.
This phase is followed by the resistance phase in which adrenaline and other like hormones are released in order to either resist or adapt to the heightened stress level. Also in preparation to deal with crisis. If the crisis” remains unresolved within an approximate time frame of three months, the body tends to show the effects of the stress buildup with ailments such as headaches, chronic back problems, as well as spastic colitis among many others.
Phase three is comprised of basic exhaustion of the body and mind from the accumulation of prolonged stress. Such chronic stress and tension as described contribute to the likelihood of another encounter with a panic attack. In addition to the ailments as mentions before, fatigue, arthritis and disease may develop.
Certain risk factors include family history, gender, and age. The ratio between males who suffer from panic disorder and females are approximately 1:3. Panic disorder usually peaks during the mid-twenties age range. In addition first degree relatives to those who suffer from panic disorder are eight times more likely to experience panic attacks themselves. Also approximately one half of those who suffer from panic disorder suffer from agoraphobia.
The cause or causes of panic disorder are unknown as of yet, however there are theories hypothesizing the cause or causes of the initial panic attack leading to panic disorder.
The suffocation alarm theory suggests that due to the common symptom of rapid breathing amongst those who suffer from panic attacks, the brain is signaling a false shortage of oxygen, or the increase of carbon dioxide in the atmosphere. Some are inclined to believe panic attacks occur in those who have developed any form of imbalance of gases in their blood enough to cause intense physical sensations.
There is another theory hypothesizing that heredity and the stress response may be the root of panic disorders. Facts supporting this hypothesis include that 30% of identical twins are concordant for panic disorder. The risk factor for a sister, brother, mother, father or child of someone with panic disorder is 10% to 20%. In addition, 40% of those who suffer from agoraphobia have a close relative who also suffers from agoraphobia. Dr. Jerome Kagan believes that children who are shy or timid differ biologically from those who are more outgoing. He based this on his experiment which illustrated that shy children respond differently from the more outgoing children on a biological level when faced with a new situation. The shy more timid children seemed to posses a higher baseline heart rate, and furthermore their pulses increase more rapidly in a new situation then those who were classified as more outgoing. The deduction drawn from this analysis was that the shy children on average had overly active stress responses. If this were to be true for the remainder of their lives, the shy children would be more susceptible to panic attacks while the more outgoing children would be relatively immune to the illness.
Following up on this research, Doctors Rosenbaum and Biederman found that children of parents who suffer from anxiety disorders were more likely to be shy then those children who did not have parents who suffer from anxiety disorders. More importantly however, they have discovered that those children who are shy tend to develop anxiety disorders in the future.
Other than heredity, researchers are looking for biological mechanisms, which may trigger panic disorders. They have yet to find such a mechanism conclusively, however, some believe that the underlying mechanism in panic disorder may involve irregularities involving norepinephrine (NE). NE is one of the brain’s neurotransmitters released in a state of emergency as well as serotonin (5-HT) or gamma-aminobutyric acid (GABA). Certain stimulants are able to interfere with NE transmission such as cocaine, amphetamines, and caffeine. Panic could be a result of the hypersensitivity of one or more of the receptors for GABA, 5-HT, or NE neurotransmitters.
Regardless of the cause, psychological consequences may persist for years following the experience, and may continue to be disabling. As in the case of Dorothy in case study B. She had a fear of driving due to her encounter with panic attacks. She anticipated that if she were to drive someplace and became trapped” she would have to escape no matter what the cost and thus may have to run out of the car, or knock someone over. In this manner the idea of another panic attack could possibly lead to such fears.
These fears could lead to actively avoiding places or situations in which the victim may feel trapped or unable to escape the oncoming panic attack. Common forms of avoidance include:
Going on airplanes
Being far away from home
Utilizing modes of public transportation
Riding on boats or ships
Traveling through tunnels
Generally enclosed places
These fears are conducive to the exaggerations of possible situations and their gravity. They often don’t rationalize the circumstance at hand, instead believe they will act on impulse due to fear and their inability to control them, thus begin to avoid situations in which they feel they will experience a panic attack or will be unable to escape if one were to occur. The mere possibility of encountering such a situation serves is adequate enough a reason for avoiding situations as previously described.
Fortunately, panic disorder is a treatable condition. There is the unconventional traditional slow breathing exercise. Frequently used for coping with feelings of general discomfort and stress. In this exercise, the emphasis is placed on the even distribution of airflow in breathing. It is suggested to create a mental image which allows for holding the breath in the abdomen for approximately eight seconds before releasing. Such as imagining being in a pool and submerging underwater then emerging to release the breath. This aids with calming the panic sufferer down.
There are certain psychotherapies which may rid of panic disorder. Two of the most common therapies available for those who suffer from panic attacks are the cognitive-behavioral therapy and exposure therapy. The first shows patients ways to understand their specific thinking patterns. The reason for this is so the patient may become able to react differently to situations which stirs anxiety within them. The later involves slowly exposing those who suffer from panic disorder in order to desensitize of their fears. Exposure to specific situations the patient associates with panic attacks.
Other treatments involving medications are available as well. Benzodiapines are effective in reducing panic attacks and phobic behavior. They are often prescribed as sleeping pills or muscle relaxants. Drugs classified under this category include clonazepam (Klonopin), alprazolam (Xanax), and lorazepam (Ativan). Benzodipines are rather effective and manage to work quickly in patients, however, withdrawal symptoms are experienced by approximately half of those who take these drugs. Furthermore, it is believed that patients who take these drugs will develop a tolerance for them. In addition, these drugs have a tendency to increase falls and may cause confusion as well as problems with memory in the elderly, thus older patients ought to be pre-cautioned and it should be distributed carefully.
Tricyclic antidepressants, imipramine such as Trofranil, nortriptyline (Aventyl or Pamelor), desipramine (Norpramin or Pertofrane) and clomipramine (Anafranil) have been found to be effective in combating panic disorder. Unlike benzodiazepines, Tricyclics require a simple daily dosage of medication. They also serve the function of guarding against depression. However the downside of Tricyclics is that they may cause side effects such as dizziness and palpitations of the heart with weight gain and sedation. Tricyclics also are slower than benzodiazepines thus are oftentimes during the initial stages of panic disorder are prescribed in combination with benzodiazepines.
MAOIs are another form of medications for panic disorder. This medication restricts the patient’s diet due to the fact that a certain substance named ttrymine when interacting with MAOIs tends to precipitate a hypotensive crisis usually characterized by a dramatic increase in blood presure.
SSRIs have been shown to posses potential as an effective method of treatment for panic disorder. Some SSRIs include paroxetine (Paxil) which has been recently approved for use when treating panic disorder, and sertraline (Zoloft) which is expected to be approved soon. SSRIs do not induce withdrawal symptoms unlike benzodiazepines and furthermore they cause less weight gain and sedation in comparison to Tricyclics.
Other factors for determining the course of treatment and receptiveness to treatment for the patient include family history. Could effect methods of behavioral therapy to be utilized on the patient due to the patient’s family background and compliance issues could effect course of treatment; may not utilize certain forms of behavioral therapy on patients who possess a certain degree of compliance issues. Degree of urgency, this is dependant on the patient’s individual case; the severity of panic disorder experienced by the patient. For example if the patient’s case is severe, benzodiazepines may be prescribed for them because benzodiazepines as mentioned earlier tend to work quickly therefore results could be seen rapidly. Especially applicable to those who suffer from panic disorder induced agoraphobia since these cases are usually the most severe in which the patient may essentially be confined to their homes.
Additional factors involved in determining the type of treatment best fit for the patient are comorbidity considerations, such as associated disorders which the patient may also posses concurrently with panic disorder. This category includes the previously discussed agoraphobia, as well as depression or any other anxiety disorders. Should it be the case that a patient seeking treatment for panic disorder has additional conflicts, treatment plans may be altered to best fit their unique situation.
It is highly recommended that any persons suffering from panic disorder see a doctor or consult with one. Some estimate that approximately 40% of all those who suffer from panic disorder do not see medical aid. However due to the possible progression of panic disorder as described by the panic spiral as well as the possible development of additional psychological conditions, it is best to seek treatment as soon as possible.
CASE STUDIES OF PANIC DISORDER
I don’t like the idea of being unable to control myself. I feel as though the world will spin out of control. When I had surgery for a biopsy, they were going to put me to sleep. The scariest part of the ordeal to me was being put to sleep. I asked the doctor to give me a local anesthetic instead of a general. He said, You know, you’re so brave. Many people would say, ‘Knock me out, knock me out.” I said to myself, ‘Little does he know that my fear is of being knocked out, of just letting go.’”
R Reid Wilson, Ph.D., Don’t Panic (New York: Harper Perennial., 1996), 122
I’ve given up on driving anywhere. I don’t want to lose my license, so I just don’t drive. I worry about having another attack while driving. If I had a panic situation driving somewhere-if there was a detour or if traffic backed up- I would either have to get out and run, or jam on the brakes, knock everybody down, knock the policeman down, go through the red lights m. I would have to escape. I can’t seem to say, Well now, calm down. You know you can. It’s only going to be a short time.” I can’t rationalize it, I don’t think at all.” I know I can but I just can’t seem to convince myself. I’m so afraid that I wouldn’t be able to tell myself that when I’m in the car, and that’s when it counts. I don’t want to be in that kind of situation.”
R Reid Wilson, Ph.D., Don’t Panic (New York: Harper Perennial., 1996), 122