Panic disorder is a type of anxiety disorder that is characterized by repeated, spontaneous and unexpected panic attacks.[1][2]. Feelings of terror will develop for no apparent reason and may trigger severe physical reactions combined with major changes in behavior or persistent anxiety over having further attacks.[3] The ongoing fear of having another panic attack can affect daily functioning and general quality of life.[4] It can cause the person to avoid places and situations where an attack has occurred or where they believe an attack will occur. Show
Upon diagnosis of panic disorder the psychiatrist must also determine whether agoraphobia is present or not. Agoraphobia refers to a irrational fear for places or situations where help is not easily accessed, escape can be difficult, or where a panic attack is likely to occur.[1][5][6] Those with agoraphobia might avoid crowded environments such as grocery stores, restaurants, malls, churches, and public transportation. This avoidance behavior may lead to the person refusing to travel outside their home or requiring to be accompanied by a friend or family member.[6] People with agoraphobia are aware that these fears are irrational.[1] Clinically Relevant Neuro-Anatomy[edit | edit source]
[1] Epidemiology/Etiology[edit | edit source]Epidemiology[edit | edit source]The lifetime prevalence of panic disorder is 1.6-4% while the onset of age is 20-29 years.[1][7] Panic disorder can be classified as with or without agoraphobia. Therefore, prevalence rates for the two classifications of the disorder exist as well. According to the National Comorbidity Study, the lifetime prevalence without agoraphobia is 3.5%, while the lifetime prevalence with agoraphobia is 5.3%.[6] Panic disorder affects about 2.4 million adult Americans and is twice as common in females.[1] Symptoms usually begin before age 25, but may occur in the mid 30s as well.[2] The onset of panic disorder can also occur prior to puberty, however, it is uncommon based on the very low prevalence (0.5-1%) of the general pediatric population. Although panic disorder may occur in children, it is often not diagnosed until they are older. If panic disorder happens to appear prior to adulthood it is more likely to be seen in adolescent females. Symptoms of panic disorder that are evident in childhood and adolescence can often lead to future psychiatric disorders. Etiology[edit | edit source]The exact cause of panic disorder has yet to be determined, however, several factors are thought to play a role in the development of this disorder. Family history, brain abnormalities, substance abuse and stress are among the factors that trigger panic attacks and furthermore, panic disorder.[8] Genetics[edit | edit source]Studies have shown that the cause is strongly correlated with the familial component. A literature review of several studies determined that individuals who have first-degree relatives with panic disorder are up to 20 times more likely to develop the disorder than control subjects.[8] Family studies of twins also support strong correlation of panic disorder and genetics. It is indicated that identical twins have a significantly higher matching rate for panic disorder than fraternal twins. Studies further suggest that if an identical twin has panic disorder 40% of the time the other twin will develop the disorder.[1][2] Autonomic Nervous System[edit | edit source]Biological theories suggest that defects in an individual’s autonomic nervous system are potential causes for the development of panic disorder. Such defects in the autonomic nervous system result in hypersensitivity, increased arousal and chemical imbalance which can lead to panic attacks.[9] Other studies reveal that abnormalities in the brain contribute to the development of panic disorder. Evidence from imaging studies have shown abnormalities in cerebral blood flow and cerebral metabolism. Furthermore, researchers believe that the brain’s limbic system, specifically the amygdala, is responsible for the misinterpretation of the significance of bodily sensations. As the amygdala misinterprets a situation, the parabrachial nucleus is stimulated causing an increase in respiratory rate while also causing an increase in norephinephrine release resulting in an increase in blood pressure and heart rate.[8] Substance Abuse[edit | edit source]Research shows a strong relationship between panic disorder and drug and alcohol abuse. It has been proposed that those with panic disorder use smoking and alcohol as a means of self-medication. However, other models suggest that substance abuse can exacerbate symptoms of panic disorder. One study indicates that smoking is three times more prevalent and harmful and that hazardous alcohol abuse is twice as prevalent in individuals with a history of panic attacks.[10] Psychological Factors[edit | edit source]Other theories suggest that panic disorder is related to psychological factors. Individuals with panic disorder commonly have a history of anxiety sensitivity in which they perceive bodily sensations to result in severe and life-threatening consequences.[11] An individual is likely to develop panic disorder if he/she has a history of physical or sexual abuse. Other potential causes include physical illness, significant life transitions, or severe stress such as the death of a family member.[12] Characteristics/Clinical presentation[edit | edit source]According to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), diagnostic criteria includes: “recurrent unexpected panic attacks” that are followed by 1 month or more of “persistent concern about having additional attacks,” “worry about the implications of the attack or its consequences,” or “significant change in behavior related to attacks.”[7] Signs and Symptoms[edit | edit source]Panic disorder is characterized by many somatic and cognitive symptoms. The following are characteristics of a panic attack which can occur at any time and generally last around 10 minutes. Four of the following symptoms must be present to meet the diagnostic criteria of panic disorder.
[1][2][4][6][13][14][15] Effects of symptoms[edit | edit source]Symptoms of panic disorder have physical, behavioral and cognitive effects:[13]
Differential diagnosis[edit | edit source]
[1][16][17] Diagnostic Procedures[edit | edit source]According to the Diagnostic and Statistical Manual of Mental Health Disorders (DSM), the following criteria is used in the diagnosis of panic disorder.[18] Panic Disorder Without Agoraphobia[edit | edit source]
Panic Disorder With Agoraphobia[edit | edit source]
Diagnostic Criteria[edit | edit source]Diagnostic Criteria for panic attacks include the presence of four or more of the following symptoms which develop with a rapid onset and peak within 10 minutes:[7]
Special Investigations[edit | edit source]To rule out other conditions, the following diagnostic and lab tests might be necessary:[4] Associated Comorbidities[edit | edit source]
[7][12][19][20] Medical Management[edit | edit source]Medical management are usually lead by a psychologist and includes a combination of the following:[20]
Pharmacological Management[edit | edit source]Anti-Depressants called Selective Serotonin Reuptaked Inhibitors (SSRI) are the first line of treatment and most commonly used medications to treat panic disorder. It may take a few weeks before anti-depressants begin to take effect, therefore, it is advised to take this medication continuously rather than only when panic attacks occur.[12] Some of the common SSRI's used to treat panic disorder include:[3]
Benzodiazepines may be used if SSRI’s do not help. This is a form of anti-anxiety medication which provides rapid relief of symptoms during a panic attack. The effects can occur as quickly as 30 minutes after taking the medication. However, this is considered to be the second line of treatment for panic disorder due to the highly addictive qualities and withdrawal symptoms that occur as a result of taking this medication.[12] Examples include:
Physiotherapy Management[edit | edit source]Physiotherapists are not involved in the primary treatment of panic disorder, however, it is important to be aware of the clinical presentation of this disorder. Patients who present to physiotherapy with panic disorder may have symptoms that mimic other medical conditions, therefore, it is necessary for the physiotherapist to recognize the need for medical referral.[16] It is also possible for patients with panic disorder to present with signs and symptoms that mimic musculoskeletal dysfunction. These are the patients who will be experiencing muscle aches as a result of panic attacks. The physiotherapist must obtain a detailed history from the patient and perform an extensive evaluation in order to determine the source of the muscle aches. Physiotherapists can play a role in helping to decrease the occurrence of panic attacks by encouraging the patient to exercise. Studies have shown that acute bouts of exercise can help to reduce or prevent the occurrence of anxiety attacks.[22] One of the suggested causes of panic disorder mentioned previously relates to abnormalities within the brain. However, exercise should be encouraged to allow the release of endorphins or the “feel good hormones” that leave a person feeling calm, energized and optimistic. Exercise also plays a role in increasing serotonin levels which in turn works to improve mood. According to the United States Surgeon General, physical activity helps to relieve symptoms of anxiety and depression as well as improve mood. If treating patients with panic disorder in the physiotherapy setting, clinicians should be advised to educate their patients on the benefits of exercise which will help manage panic disorder. It is also recommended to be aware that it is possible for exercise to induce panic attacks. Therefore, therapists should pay close attention to changes in signs and symptoms of these patients during exercise. Resources[edit | edit source]References[edit | edit source]
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