Panic Disorder Classifications and Pathogenesis

gregorkowalnew

Dr Gregor Kowal
Senior Consultant
in Psychiatry and Psychotherapy,
German Board Certified,
Medical Director,
Clinic for Health and Medical Care
Phone: 00971-4-4574240

panic attack describes a state of intense fear or discomfort emerging suddenly, often without warning, and for no apparent reason from either a calm or anxious state. During the panic attack various other psychological as well as physical symptoms may occur. These powerful and upsetting symptoms will scare the person into experiencing variety irrational thoughts, such as:  “I`m dying”/ “I`m going crazy”/” I`m about to faint or lose control”/” I have to escape from here”, etc.

Despite their severity the symptoms occurring with panic attacks do not mean there is a physical problem with the heart, chest, etc. The symptoms occur because of an “overdrive” of the autonomous nervous system, which is inappropriate to the circumstances. During a panic attack the person tends to over-breathe (hyperventilate), which blow out too much carbon dioxide causing a rise of the blood pH, known as respiratory alkalosis. This triggers even more symptoms such as confusion, cramps, heart palpitations, and dizziness making the attack more frightening. Sufferers of panic attacks report a fear of dying (usually of a “heart attack”), flashing vision, nausea, numbness throughout the body, heavy breathing and loss of bodily control sometimes ending in a faint. Some people suffer also from tunnel vision. Common psychological reaction associated with panic attacks is depersonalization (being detached from oneself).  A panic attack usually lasts 5-10 minutes, but sometimes longer for up to two hours.

The effects of a panic attack vary. Some, notably first-time sufferers, may call for emergency services. Panic attacks are of acute onset combining the above mentioned physical symptoms followed by a period of residually impaired psychological functioning. After a first occurrence, the panic attack will inevitably tend to manifest itself again. As a result of a vicious circle that brings about an automatic response to any anxiety-provoking anxiogenous signal, the attacks tend to reoccur and to increase in intensity. Once the attack has been unleashed, the patient feels dominated by an escalating sequence of events which appear to follow an unstoppable progressive course. Created in the imagination but also concretely experienced by the patient, the panic attack, once occurred, establishes itself as a traumatic event.

Panic disorder is a condition where the patient experiences recurring panic attacks. In panic disorder the person will have usually ongoing worry about having further attacks (anticipatory anxiety) as an effect of conditioning.

Panic attacks are different from the “physiological” anxiety experienced in dangerous situations. Such anxiety doesn`t influence the rational thinking; in contrary the thinking speed and the level of concentration are increased, preparing the individual for the “fight or flight” reaction. In such cases the people are simply afraid of an expected dangerous situation and the fear allows them to anticipate their reactions and to consider ways of avoiding the danger. We are able to think even when we feel anxious. During a panic attack the activation happens “out of the blue” without any visible causes. Once a panic attack started it will progress automatically in not controllable way paralyzing thinking and not allowing for interventions based on rational decisions.

On the diagnostic level the panic disorder is differentiate from the anxiety released by certain situations.  Such conditions as agoraphobia – or claustrophobia(anxiety released by wide or small spaces), phobias related to animals and other known situations (for example flying phobia) will unleash the same symptoms and dynamics as a panic attack. The only difference between them is the fact that the phobic anxiety is released by identifiable circumstances.

Anxiety is a natural and universal experience, which human beings share with all mammals. Since it is ubiquitous, it serves a biological function. The biological function of anxiety is crucial for the survival in the world full of dangerous situations, preparing the individual to meet whatever emergencies may arise. The actual experience of anxiety is directly associated with physiological changes that prepare the body violent action: the heart rate increases, the blood pressure rises, adrenaline is secreted, the energy stores are mobilized in the liver and released into the bloodstream, blood is redistributed from the internal organs so as to carry oxygen and energy the muscles and the brain will use to master the danger. Those changes are caused by activation of the sympathetic nervous system preparing the organism for the fight or flight response.

In the environment of evolutionary adaptedness the anxiety is essential to survival. In the modern world, however, the physiological function of anxiety is “misguided” or exaggerated becoming a symptom.  A crucial question is: why a natural psychophysiological response (anxiety) became exaggerated into a persistent and inappropriate state, called by the founder of the psychotherapy Sigmund Freud “anxiety neurosis” and categorized by the current classification manuals as different “anxiety disorders”. The answer to this question could be following: the species Homo sapiens was “designed” to live in stable social groups, frequently struggling to survive in dangerous situations but at the same time living in balance with the nature. We will not find any anxiety disorders in hunters and gatherers of the Kalahari Desert living a very similar life to those of our remote ancestors.

In contrary to the evolutionary developed model of life, the modern man lives in large dense and overcrowded cities called by Desmond Morris the “Human Zoo”(Desmond Morris:  “The Human Zoo: A Zoologist`s Study of the Urban Animal”). In the mentioned book we can readUnder normal conditions, in their natural habitats, wild animals do not mutilate themselves, attack their offspring, develop stomach ulcers, become fetishists, suffer from obesity, or commit murder. Among human city dwellers, needless to say, all of these things occur…  Other animals do behave in these ways under certain circumstances, namely when they are confined in the unnatural conditions of captivity. The zoo animal in a cage exhibits all these abnormalities that we know so well from our human companions. Clearly, then, the city is not a concrete jungle, it is a human zoo.

1. Diagnostics

The current diagnostic manuals (DSM V and ICD 10) categorize the criteria for different psychiatric disorders concentrating on the symptoms and not on the etiology (root cause) of the illness. Those diagnostic manuals are useful as they create a communication platform for psychiatrists.

The diagnostic manual (DSM V) of the American Psychiatric Association`s (APA) describes the panic attack, the panic disorder and their diagnostic criteria asfollows:

Panic Disorder, DSM V 300.01 (ICD 10: F41.0)

A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes and during which time four (or more) of the following symptoms occur:

1. Palpitations, pounding heart, or accelerated heart rate.

2. Sweating.

3. Trembling or shaking.

4. Sensations of shortness of breath or smothering.

5. Feelings of choking.

6. Chest pain or discomfort.

7. Nausea or abdominal distress.

8. Feeling dizzy, unsteady, light-headed, or faint.

9. Chills or heat sensations.

10. Paresthesias (numbness or tingling sensations).

11. Derealization (feelings of unreality) or depersonalization (being detached from oneself).

12. Fear of losing control or “going crazy.”

13. Fear of dying.

B. At least one of the attacks has been followed by 1 month (or more) of one or both of the following:

1. Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, “going crazy”).

2. A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations).

3. The disturbance is not attributable to the physiological effects of a substance(e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary disorders).

4. The disturbance is not better explained by another mental disorder(e.g., the panic attacks do not occur only in response to feared social situations, as in social anxiety disorder; in response to circumscribed phobic objects or situations, as in specific phobia;  in response to obsessions, as in obsessive-compulsive disorder; in response to reminders of traumatic events, as in posttraumatic stress disorder; or in response to separation from attachment figures, as in separation anxiety disorder).

Remarks:

– The abrupt surge can occur from a calm state or an anxious state.

  Panic attacks can occur in the context of any anxiety disorder as well as other mental disorders (e.g., depressive disorders, posttraumatic stress disorder, substance use disorders) and some medical conditions (e.g., cardiac, respiratory, vestibular, gastrointestinal).

– Culture-specific symptoms (e.g., tinnitus, neck soreness, ache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms.

2. Causes

The approach that anxiety disorders are the effect of frustration of our evolutionary developed adaptedness caused by the modern life style, remains valid. The next crucial question is related to the morbidity (the proportion of a population suffering from the condition) of the anxiety disorders: why only a small percentage of the population develops this kind of disorders?

Based on different studies several factors have been identified:

2.1 Biological factors:

 Genetics: Various twin studies where one identical twin has an anxiety disorder have reported around 50% incidence of the other twin also having an anxiety disorder diagnosis.

 Neurophysiological factors like certain changes in the brain pathways. According to the neuroscientific hypotheses, the somatic (bodily) anxiety cousing a multitude of physical and psychological symptoms derives from an improper activation, through the limbic system, of primitive neurobiological or neurochemical mechanisms that start from the amygdala and cause a short circuit of psychosomatic responses.

– Environmental factors such as major stress, an overly cautious view of the world expressed by parents and cumulative stress over time have been found to be correlated with panic attacks. Other factors are: significant personal loss, life transitions and major life changes.

Although the evidence for neurophysiological factors in panic disorder is impressive, these observations are more persuasive regarding the vulnerability for panic attacks than their onset.

2.2 Psychological aspects 

A few major psychological theories try to account for etiology (root cause) of panic disorder.  Most of them rest on explanation of several lines of evidence, turning around the influence of life events and experience like home environment, social learning, separation anxiety, loss of a loved one, childhood trauma and other negative experiences as well as influence of recent life events. The other aspect is  the impact of temperament and predisposition. Patients with panic disorder have been found to have a higher incidence of stressful live events, particularly loss. Understanding the pathogenesis of panic disorder from the attachment theory perspective is also helpful in a psychodynamic approach to the treatment.

The psychodynamic viewpoint is based on the idea that panic attacks are the expression of an intrapsychic conflict and that the patients could benefit from a psychotherapeutic process exploring the unconscious.

For cognitivism, panic derives from a perceptive distortion of the fear signals and the recommended therapy is based on a combination of cognitive reconstruction and gradual exposures of the patient to the terror-inducing stimuli.

The anxiety in panic attacks  has some features similar to those found in traumatized individuals, but it has also its own specific characteristics, such as the fact of occurring suddenly, a tendency to repetition and a lack of recognition of the sequence of events leading to it.

3. Treatment

Panic attacks and panic disorder are treatable conditions and can be effectively treated with a variety of interventions including medication and psychological therapies.

3.1 Medication treatment for panic attacks and panic disorder

Medication is able to reduce or even fully suppress the symptoms of the panic disorder. In severe cases of panic disorder the pharmacological treatment “opens the door” for the psychotherapy. Patients “paralyzed” by severe panic attacks are too fragile and not accessible for psychotherapy. The medication works quickly reducing the symptoms within days being able to suppress completely the symptoms within few weeks. Despite of its effectiveness the medication will not resolve the problem.  The state of the art treatment of panic disorder is the combination of medication (highly effective in short time) and the psychotherapy that addresses the underlying causes of panic disorder. According to author`s own clinical experience the symptoms of panic attacks can be fully suppressed in nearly all cases. Yet the suppression of the symptoms with medication doesn`t mean that the patient has been “cured”. A stable mental condition will protect him from the terror of panic attacks. The patient will be able maintain his private and professional performance winning time for the long lasting process of the psychotherapy. The psychotherapy is more effective in long term (more than one year) in compare with the pharmacological treatment.

The medication used for panic attacks and panic disorder includes:

– Benzodiazepines

These anti-anxiety drugs act very quickly. Taking them during a panic attack provides rapid relief of symptoms in as little as ten or fifteen minutes. However, benzodiazepines should be used only for few weeks in the initial stage of the treatment. Benzodiazepines do not treat the source of the underlying fear but rather offer rapid onset relief from the immediate symptoms.

– Antidepressants

This group of medication is used in treatment of depression but they are also very effective in treatment of panic disorder. They do not work straightaway. It takes few weeks before their effect builds up and may take up to 8-12 weeks to work fully. There are several types of antidepressants. The proper choice of the medication and the psychotherapy technic is crucial for the effectiveness of the treatment.

3.2 Psychotherapy

3.2.1 Behavioral therapy (exposure therapy)

In exposure therapy for panic disorder the patient will be exposed to the physical sensations of panic in a safe and controlled environment, giving him the opportunity to learn healthier ways of coping. The psychotherapist may provoke sensations similar to the symptoms of panic. With each exposure, the patient can become less afraid of these internal bodily sensations feeling a greater sense of control. Through this experience the patient learns that the situation isn`t harmful. Behavioral therapy aims to identify and change the harmful pattern of behavior.

3.2.2 Cognitive therapy

Cognitive therapy is based on the idea that certain ways of thinking can trigger and maintain certain mental conditions such as panic attacks. The therapy is focused on the understanding of patient`s thought patterns, in particular, to identify any harmful, unhelpful, and mistaken ideas or thoughts. The aim of the cognitive therapy is to change the way of thinking to avoid the pathogenic ideas and help to create more realistic and helpful thought patterns.

3.2.3 Cognitive Behavioral Therapy (CBT)

Cognitive Behavioral Therapy is a mixture of the above described therapies where the patient benefits from changing both thoughts and behaviors. Cognitive behavioral therapy is generally viewed as the most effective form of treatment for panic disorder. Cognitive behavioral therapy focuses on the thinking patterns and behaviors that are sustaining or triggering the panic attacks. It helps the patient create insight showing his fears in a more realistic light. Once the patient learned that nothing truly disastrous is going to happen, the experience of panic becomes less terrifying.

3.2.4 Psychodynamic Psychotherapy

Psychoanalytic/psychodynamic treatment for panic disorder attempts to uncover the unconscious psychological meaning of panic; the treatment focuses on psychodynamic conflicts that include separation/autonomy and anger expression/management. From a psychoanalytical point of view we could claim that panic attacks are provoked by a fragile self-defencelessness, which opens the gates to overwhelming anxiety. Indeed, clinical experience teaches us that the symptom of panic is always accompanied by an identity defect and betrays a failure of the self.

In less complex cases, the panic attack signals the collapse of narcissistic organization. For this reason, panic attacks are particularly common in mid-life crises (when the myth of one`s own efficiency, beauty or success can no longer contain the anxieties concerning the limitations of one`s existence) or in those reactions to being abandoned where separation from one`s partner is experienced as a collapse of the self and of one`s sense of security.

From the psychodynamic point of view the treatment of a patient with panic attacks require two conditions. The first condition is to help them understand the underlying cause (the conflict) being responsible for the anxieties that devastate them. Alone this process of understanding can reduce the intensity as well as the frequency of panic attacks; knowing the “inner landscape” the patient will sooner or later implement changes in his life. The second condition is to help the patient build a stable and permanent sense of self. This means helping analysands to develop its own individuality with the capacity to formulate autonomous opinions and thoughts in order to attain emotional experiences that can be free from inhibitions, self-indulgences or unconditional conformity. The psychodynamic psychotherapy focus on the root causes of the disorder and less on the symptoms. This approach is causal in its nature. The psychotherapeutic process lasts for several months sometimes even up to two years.

Most of the surveys compared the behavioral, cognitive and cognitive behavioral therapy with the evidence that the latest has the longest duration of effect. Recent studies have shown that psychodynamic psychotherapy is equally effective in relieving panic attacks as behavioral approaches and has fewer relapses.

http://www.ncbi.nlm.nih.gov/pubmed/17267789

History

The historical description of the anxiety disorders called today: “panic disorder” and “generalized anxiety disorder”, was introduced by Sigmund Freud under the term: “anxiety neurosis” (German: “Angstneurose”).  As in both disorders there were no visible stimuli triggering their onset, Freud called them initially “neurosis without conflict”. Later Freud changed his viewpoint on this kind of anxiety, giving increasingly more relevance to unconscious conflicts which should be revealed in the analytical process.

In his paper from December 1894 “On the grounds for detaching a particular syndrome from neurasthenia” he wrote: “In some cases of anxiety neurosis no etiology(root cause) at all is to be discovered. It is worth noting that in such cases there is seldom any difficulty in establishing evidence of a grave hereditary taint. But where there are grounds for regarding the neurosis as an acquired one, careful enquiry directed to that end reveals that a set of noxae and influences from sexual life are the operative etiological factors”.

Freud paid attention to the fact of higher occurrence of anxiety symptoms running in the members of the same family. For the cases without a family history he related the origin of anxiety to sexual suppression. From today`s perspective (and author`s own clinical experience) we can conclude that the Freudian link to the suppressed sexuality is valid only in a very low percentage of the anxiety disorders.

In the last 100 years the psychoanalytical terms: “neurosis”, “neurasthenia” or “hysteria” found their use in the common language getting gradually a pejorative overtone. In the current psychiatric diagnostic manuals this terms have been replaced by “politically correct” word: “disorder”.

On the symptomatic level Freud`s description of the anxiety neurosis correlates astonishingly with the current description of a panic attack. In the above mentioned paper we can read:

“I append here a list which includes only those forms of anxiety attack which are known to me:

(a) Anxiety attacks accompanied by disturbances of the heart action, such as palpitation, either with transitory arrhythmia or with tachycardia of longer duration which may end in serious weakness of the heart and which is not always easily differentiated from organic heart affection; and, again, pseudo-angina pectoris – diagnostically a delicate subject!

(b) Anxiety attacks accompanied by disturbances of respiration, several forms of nervous dyspnoea, attacks resembling asthma, and the like. I would emphasize that even these attacks are not always accompanied by recognizable anxiety.

(c) Attacks of sweating, often at night.

(d) Attacks of tremor and shivering which are only too easily confused with hysterical attacks.

(e) Attacks of ravenous hunger, often accompanied by vertigo.

(f) Diarrhoea coming on in attacks.

(g) Attacks of locomotor vertigo.

(h) Attacks of what are known as congestions, including practically everything that has been termed vasomotor neurasthenia.

(i) Attacks of paraesthesias (numbness). (But these seldom occur without anxiety or a similar feeling of discomfort.)”

Summary

A panic attack describes a state of intense fear combined with variety of symptoms like chest pain, flashing vision, nausea, numbness and very frequent a subjective feeling of an immediate death. The panic attack feels like an inexplicable and unthinkable traumatic event. “The panic episode is like a repetitive micro-delusion exposing the patient to a concrete experience of dying, suddenly facing him with a `nameless dread` and provoking in him that fear of annihilation, biological as well as psychological, that has the power of destructuring the mind and damaging any sense of existential continuity and integrity” (Quoted after Francesco De Massi).

Panic is different from other forms of anxiety in so far as it is activated automatically, it paralyses thinking, and it does not allow the affected individual for interventions based on rational thinking. In the different case of people who are simply afraid of an expected dangerous situation, such a fear allows them to anticipate their reactions and to consider ways of avoiding the danger.

In the course of the panic attack, psychological and biological mechanisms intersect and mutually reinforce each other. There are different neurobiological factors increasing the vulnerability for a panic attack. The onset of panic attack is triggered by certain psychological circumstances the patient is not aware of (unconscious conflict). The recurring panic attacks, described as a panic disorder, are reinforced by conditioning (learned behavior).

Panic disorder is a treatable condition with a good prognosis. The state of the art therapy is a combination of pharmacological treatment (medication) and the psychotherapy. Most of the surveys show the high effectiveness of cognitive behavioral therapy (CBT) as well as psychodynamic psychotherapy.