Panic Disorder

Contributors:
A. Stephen Lenz, Ph.D., LPC, Texas A&M University-Corpus Christi, Samantha Klassen, MS, LPC-Intern, Texas A&M University-Corpus Christi

Panic disorder is characterized in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychological Association [APA], 2013) by persistent, yet unexpected panic attacks (Criterion A). These episodes of fear and extreme distress are followed by at least one month of worrying about or modifying of daily activities in an attempt to avoid further panic episodes (Criterion B) that cannot be attributed to substance use or medical conditions (Criterion C), and are not better explained by another psychiatric disturbance (Criterion D). A key feature of this disorder is the unexpected emergence of symptoms that tend to peak relatively quickly, within about 10 minutes. During this brief episode, individuals experience at least four somatic and cognitive symptoms including (but not limited to) accelerated heart rate, sweating, trembling, chest pain, shortness of breath, fear of losing control, and fear of dying.

Given the high prevalence of anxiety disorders, it is likely that counselors across settings will encounter clients who meet criteria for treatment of panic disorder. Lifetime prevalence estimates indicate that approximately 3.8% of individuals within the United States will experience panic disorder (APA, 2013; Kessler et al., 2012). Among this subgroup, women tend to report panic disorder symptoms about twice as often as men. Several researchers have cited robust evidence illustrating strong associations between genetic, neuroanatomical, and socio-contextual variables and the emergence of panic disorder. Family studies have indicated that individuals who have a first-degree family member with a history for panic attacks are between 6-17 times more likely to develop panic disorder than those without a positive family history (Na, Kang, Lee, & Yu, 2011). Structural, metabolic,and functional investigations of the nervous system have implicated the limbic system and prefrontal cortices as mediating the fear and anxiety responses associated with panic disorder (Dresler et al., 2013). In particular, the dysregulation of neurotransmitters and hormones such as dopamine, serotonin, norepinephrine, orexin, and adenosine appears to influence panic symptoms, and may cause panic disorder (Geiger, Neufang, Stein, & Domschke, 2014).

Identification/Assessment Strategies

Panic disorder can resemble several serious medical, psychiatric, or cultural syndromes; therefore, a prudent approach to evaluation will integrate multiple modalities and include reporting from both clients and collaterals. We recommend conducting a clinical interview, referring for a medical evaluation, conducting a behavioral assessment, and reviewing self-report data. A comprehensive clinical interview should include data related to: (a) onset, severity, and frequency of panic attacks; (b) developmental issues that may have influenced presence of panic attacks; (c) history of abuse, neglect, or maltreatment; (d) history of problematic substance use; (e) family dynamics; (f ) cultural factors that may account for interpretation of symptoms; and (g) the degree that symptoms have been associated with endangerment of self or others. Clinical interview data are then integrated with results from a medical examination to rule out etiology related to cardiopulmonary conditions, hyperthyroidism, vestibular dysfunction, or seizure disorders.

Comprehensive assessment of panic disorder can be facilitated by use of several formal rating scales including the DSM-5 Severity Measure for Panic Disorder (Craske et al., 2013), the Patient Health Questionnaire (Spitzer, Kroenke, & Williams, 1993), the Panic Disorder Self-Report (Apfeldorf, Shear, Leon, & Portera, 1994), and the Anxiety and Related Disorders Interview Schedule for DSM-5 (Brown & Barlow, 2014). Each of these assessments provides users with cutoff scores to designate client symptom severity within clinically relevant ranges such as mild, moderate, and severe. In addition to these formal assessments, several online resources are available to clients through free, web-based platforms such as those provided by Anxiety and Depression Association of America (www.adaa.org) and the Institute of Living (http://www.harthosp.org/Instituteofliving/default.aspx). The self- assessments offered by these groups are intended to support education, prevention, and treatment of anxiety disorders, including panic disorder.

Resources:
Anxiety and Depression Association of America Self-Assessment: http://www.adaa.org/screening-panic-disorder

DSM-5 Severity Measure for Panic Disorder Adult and Children Forms: https://www.psychiatry.org/psychiatrists/practice/dsm/dsm-5/online-assessment-measures#Disorder

Institute of Living Panic Disorder Self-Assessment: https://instituteofliving.org/File%20Library/Assessment%20Tools/Panic-Assessment.htm

Patient Health Questionnaire Free Screeners for generalized anxiety disorder, panic disorder, and other psychiatric syndromes: http://www.phqscreeners.com/

 

Intervention Strategies

According to the National Institute of Mental Health (2013), panic disorder is usually treated with psychotherapy, medication, or a combination of both. Panic disorder is associated with relationship difficulties, impaired problem-solving ability, reduced job productivity, and reduced ability to care for children or other dependents (Otto et al., 2012). Because of the multitude of difficulties associated with panic disorder, a multi-pronged treatment approach is often needed to address pervasive impairments in functioning. As previously mentioned, we recommend referring clients with panic disorder to their physicians for a medical evaluation to ensure both psychological and physiological symptoms are addressed.

Cognitive Behavioral Therapies (CBT)
Cognitive behavioral therapy (CBT) is the primary psychotherapeutic modality used in the treatment of panic disorder. CBT for panic disorder can be delivered in individual, group, and internet-based formats, with each modality successfully reducing global symptom severity and impairment in occupational or domestic functioning (El Alaoui et al., 2013). We recommend discussing treatment expectations and preferences with clients to improve retention, as clients with anxiety disorders are often at higher risk for premature termination (Perreault et al., 2014).

CBT for panic disorder generally includes psychoeducation, stress management, relaxation training, and cognitive restructuring exercises wherein clients learn to evaluate and modify distressing cognitions. A key difference between general CBT and CBT for panic disorder is the inclusion of interoceptive exposure. During interoceptive exposure, clients are instructed to produce physical symptoms associated with a panic attack (e.g., hyperventilation) in session in order to practice applying cognitive and behavioral strategies and facilitate habituation, thus reducing the intensity and duration of attacks (Gaudlitz, Plag, Dimeo, & Strohle, 2015). Beyond traditionally-delivered individual, group, or internet-based CBT, panic disorder may also be successfully treated with intensive, time-limited cognitive behavioral interventions. For example, clients have experienced clinically significant, meaningful symptom remission and sustained improvements in functioning in as little as five sessions using a manualized treatment protocol referred to as “ultra-brief ” cognitive behavioral therapy (Otto et al., 2012).

Pharmacological Interventions
The pathophysiology of panic disorder involves surges of intense fear related to elevated levels of catecholamines such as norepinephrine, epinephrine, and dopamine in the brain. Some individuals may be successfully treated with medications intended to balance levels of these three key neurotransmitters (Oh et al., 2015). Van Apeldoorn et al. (2014) recommend treatment with a selective serotonin reuptake inhibitor (SSRI) in conjunction with CBT as the most optimum, cost-effective modality. An SSRI called paroxetine (brand name Paxil or Pexeva) may positively impact the brain’s ability to regulate catecholamines, but additional research is needed to determine its efficacy (Oh et al., 2015). Sertraline (brand name Zoloft), another SSRI, has been effective in preventing the resurgence of panic disorder symptoms and is considered another first-line psychopharmacological intervention (Rapaport et al., 2001). In a more recent clinical trial comparing the efficacy of self-administered CBT (SCBT) and treatment with sertraline, analyses of trends over time confirmed that sertraline and SCBT produced greater declines in symptoms associated with panic disorder than SCBT or pharmacological treatment alone (Koszycki, Taljaard, Segal, & Bradwein, 2011).

Resources:
About Zoloft: http://www.zoloft.com/about-zoloft

Handbook of Clinical Psychopharmacology for Therapists: https://www.amazon.com/Handbook-Clinical-%20Psychopharmacology-Therapists-Preston/dp/1608826643/ref=sr_1_1?ie=UTF8&qid=1442785457&sr=8-%201&keywords=Handbook+of+clinical+psychopharmacology+for+therapists

What is Paxil? http://www.drugs.com/paxil.html

Adjunctive Treatments
Beyond psychotherapy and pharmacological treatment, aerobic exercise is recommended as an adjunct intervention for the treatment of panic disorder. Gaudlitz, Plag, Dimeo, and Strohle (2015) found clients who participated in eight weeks of endurance training (30 minutes of cardiovascular exercise on a treadmill 3 times per week) in conjunction with group CBT experienced fewer panic-specific symptoms than those clients receiving psychotherapy alone. In addition to aerobic exercise, other lifestyle changes potentially mitigating the symptoms of panic disorder include decreasing caffeine consumption, engaging in activities that feature a mindfulness component, and developing a self-care routine.

Resources
For Counselors
Academy of Cognitive Therapy: http://www.academyofct.org/panic-disorder/

Anxiety and Depression Association of America: http://www.adaa.org/

Anxiety Disorders in Adults: An Evidence-Based Approach to Psychological Treatment: https://www.amazon.com/Anxiety-Disorders-Adults-Evidence-Based-Psychological/dp/0195116259

Cognitive Behavioral Therapy Worksheets for Panic: http://psychology.tools/panic.html

The Anxiety and Phobia Workbook: http://www.amazon.com/Anxiety-Phobia-Workbook-Edmund-Bourne/

dp/1626252157/ref=sr_1_2?ie=UTF8&qid=1442784379&sr=8-2&keywords=cbt+for+panic+disorder

For Clients
Mastery of Your Anxiety and Panic: Workbook: https://www.amazon.com/Mastery-Your-Anxiety-Panic-Treatments/dp/0195311353/ref=sr_1_1?ie=UTF8&qid=1442783651&sr=8-1&keywords=cbt+panic+disorder

ADAA Mobile Apps: http://www.adaa.org/finding-help/mobile-apps

PsychForums: http://www.psychforums.com/panic-disorder/

Self Help Tools for Panic: A CBT Workbook for Overcoming Panic Attacks: https://www.amazon.com/Self-help-%20tools-panic-workbook-overcoming/dp/0993296807/ref=sr_1_6?ie=UTF8&qid=1442783651&sr=8-%206&keywords=cbt+panic+disorder

REFERENCES

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, D.C.: American Psychiatric Association.

Apfeldorf, W. J., Shear, M. K., Leon, A. C., & Portera, L. (1994). A brief screen for panic disorder. Journal of Anxiety Disorders, 8, 71-78.

Brown, T. A., & Barlow, D. H. (2014). Anxiety and Related Disorders Interview Schedule for DSM-5 (ADIS-5) - Lifetime Version. New York, NY: Oxford University Press.

Craske, M., Wittchen, U., Bogels, S., Stein, M., Andrews, G., & Lebeu, R. (2013). DSM-5 Severity Measure for Panic Disorder. Retrieved from http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measure#Disorder

Dresler, T., Guhn, A., Tupak, S. V., Ehlis, A-C., Herrmann, M. J., Fallgatter, A. J., … Domschke, K. (2013). Revise the revised? New dimensions of the neuroanatomical hypothesis of panic disorder. Journal of Neural Transmission, 120, 3-29. doi:10.1007/s00702-012-0811-1

El Alaoui, S., Hedman, E., Ljotsson, B., Bergsrom, J., Andersson, E., Ruck, C., … Lindefors, N. (2013). Predictors and moderators of internet- and group-based cognitive behaviour therapy for panic disorder. PLoS One, 8, 1-8. doi:10.1371/journal.pone.0079024

Gaudlitz, K., Plag, J., Dimeo, F., & Strohle, A. (2015). Aerobic exercise training facilitates the effectiveness of cognitive behavioral therapy in panic disorder. Depression and Anxiety, 32, 221-228.

Geiger, M. J., Neufang, S., Stein, D. J., & Domschke, K. (2014). Arousal and the attentional network in panic disorder. Human Psychopharmacology, 29, 599-603. doi:10.1002/hup.2436

Kozycki, D., Taljaard, M., Segal, Z., & Bradwejn, J. (2011). A randomized trial of sertraline, self-administered cognitive behavior therapy, and their combination for panic disorder. Psychological Medicine, 41, 373-383. doi:10.1017/S0033291710000930

Na, H.-R., Kang, E.-H., Lee, J.-H., & Yu, B.-H. (2011). The genetic basis of panic disorder. Journal of Korean Medical Science, 26, 701–710. doi:10.3346/jkms.2011.26.6.701

National Institute of Mental Health. (2013). Panic disorder. Retrieved from http://www.nimh.nih.gov/health/topics/panic-disorder/index.shtml

Oh, J., Yu, B., Heo, J., Yoo, I., Song, H., & Jeon, H. J. (2015). Plasma catecholamine levels before and after paroxetine treatment in patients with panic disorder. Psychiatry Research, 225, 471-475.

Otto, M. W., Tolin, D. F., Nations, K. R., Utschig, A. C., Rothbaum, B. O., Hofmann, S. G., … Smits, J. A. (2012). Five sessions and counting: Considering ultra-brief treatment for panic disorder. Depression and Anxiety, 29, 465-470. doi:10.1002/da.21910.

Perreault, M., Julien, D., White, N. D., Belanger, C., Marchand, A., Katerelos, T., … Milton, D. (2014). Treatment modality preferences and adherence to group treatment for panic disorder with agoraphobia. Psychiatric Quarterly, 85, 121-132. doi:10.1007/s11126-013-9275-1

Rapaport, M. H., Wolkow, R., Rubin, A., Hackett, E., Pollack, M., & Ota, K. Y. (2001). Sertraline treatment of panic disorder: Results of a long-term study. Acta Psychiatrica Scandinavica, 104, 289-298.

Spitzer, R. L., Kroenke, K., Williams, J. B., & Patient Health Questionnaire Primary Care Study Group. (1999). Validation and utility of a self-report version of PRIME-MD. Journal of the American Medical Association, 282, 1737-1744.

Van Apeldoorn, F. J., Stant, A. D., van Hout, W. J. P. J., Mersch, P. P. A., & den Boer, J. A. (2014). Cost-effectiveness of CBT, SSRI, and CBT+SSRI in the treatment for panic disorder. Acta Psychiatrica Scandinavica, 129, 286-295. doi:10.1111/acps.12169

Published: December 2015
Updated: August 2016

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