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What Causes Panic Disorder?

What Causes Panic Disorder?



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That intense feeling of fear is back. Your pulse races, you begin to sweat, and you feel you’re losing control. It’s another panic attack.

Once it’s over, your fear doesn’t subside, though. You’re now fearing fear itself. You start looking for ways to avoid another episode, even if this means changing most of your routines.

Fear of panic attacks is now a central focus of your life.

If this is familar, and you can’t stop worrying about having another panic attack, you might be living with panic disorder.

Although overwhelming, this condition can be managed and treatment is available. A path to recovery might begin with learning about the disorder’s possible causes.

Anxiety and panic disorder are closely related, Gene Beresin, MD, MA, told.

In fact, panic disorder is considered an anxiety disorder.

An anxiety disorder is a mental health condition characterized by excessive and intense fear and changes in behavior based on such fear. There are a few types of anxiety disorder.

“Any of the anxiety disorders can trigger a panic attack,” says Beresin, executive director of The Clay Center for Young Healthy Minds at The Massachusetts General Hospital in Boston.

But not all anxiety disorders are panic disorders. When you live with panic disorder, you have recurrent panic attacks. Or you may live in fear of having attacks. Consequently, you change your behavior to prevent the occurrence of another one.

“One of the problems, when panic attacks strike, is that they become associated with the place or situation where they occur,” Beresin says.

Once a place is linked to a panic attack, you tend to do everything possible to avoid that place.

For someone living with panic attacks, even thinking about these triggering places or situations might be enough to bring on “anticipatory anxiety,” the fear that another panic attack will occur.

Sometimes this fear alone is enough to cause you to experience a panic attack. When you have multiple panic attacks and persistently avoid certain scenarios, you may have crossed the threshold into panic disorder.

You may wonder if there is one specific cause of panic disorder. Was there an event you witnessed? A genetic trait you have? Did past circumstances lead you here?

You might say that anxiety causes panic disorder. But it’s not that straightforward. In fact, many people who experience panic attacks don’t develop panic disorder.

As with many mental health conditions, the root causes of panic disorder are not well understood yet.

Many factors may come into play. In some rare cases, underlying medical conditions can also explain the condition.

“It’s important to have a complete medical examination. What may appear to be panic disorder could be a medical illness, such as thyroid or other hormonal diseases, cardiac disorder, seizures or other illnesses that present themselves as panic disorder,” says Beresin.

Once an underlying medical condition has been ruled out, other contributing factors are taken into consideration, including:

  • genetics
  • biology
  • psychosocial influences
  • presence of other mental health conditions

Genetics and biological causes

Genetics appears to have a link to panic disorder in some cases.

A 2018 literature review found a few studies that suggested that having first-degree relatives who live with panic disorder increases the chance of developing the condition.

The same review found that females may have a higher genetic predisposition to panic disorder.

In fact, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) notes that panic disorder is more often diagnosed in females than males at a rate of approximately 2:1.

The manual also states that children of parents living with mental health conditions such as anxiety, bipolar, and depressive disorders might have an increased chance of developing panic disorder.

Although it’s believed that some genes might be at play, there’s still no scientific evidence that points to specific ones or certain genetical functions.

Changes in parts of the brain such as the amygdala, temporal lobe, and medial temporal lobe may also contribute to the development of panic disorder.

Psychosocial and environmental causes

Psychosocial factors refer to how the things and people in your environment affect your thoughts and emotions.

When it comes to the causes of panic disorder, life experiences, childhood observations, and parental influences may all increase what is known as anxiety sensitivity.

A 2018 study showed that anxiety sensitivity is a suspected contributing cause of panic disorder.

When you live with anxiety sensitivity, you tend to believe that any sign or symptom of anxiety poses a serious risk to your health.

For example, if you feel tightness in your chest, you might immediately think you’re having a heart attack. If you experience shortness of breath, you might believe you’re about to faint.

This fear, in turn, increases your anxiety levels and might lead you to experience recurrent panic attacks.

If you have anxiety sensitivity, you’re also more likely to fear panic attacks. This might cause you to experience more of these episodes, and so a vicious cycle begins.

Other possible environmental causes of panic disorder include:

  • sexual and physical abuse
  • trauma during childhood or adulthood
  • significant childhood or adult losses
  • use of prescription or illicit substances
  • chronic physical illnesses

Presence of other mental health conditions

Berensin notes that the development of panic disorder may be associated with the occurrence of other mental health conditions such as:

  • PTSD
  • substance use disorders
  • withdrawal syndromes from addictive substances
  • depressive disorder
  • bipolar disorder

Some external and internal factors can increase your chances of developing a panic disorder, including:

  • chronic stress
  • repeated personal losses
  • phobias
  • fear of going places for reasons other than fear of a panic attack
  • social isolation
  • performance anxiety
  • significant lifestyle changes (such as moving to a new country that has a different language and culture)

Living with panic disorder can affect many aspects of your life.

The exact cause of panic disorder is still unknown. Still, the condition is often linked to anxiety sensitivity and having a first-degree relative with the same or other mental health condition.

Although overwhelming, panic disorder is treatable. Symptoms can be managed with the help of a mental health professional.


What Causes Panic Disorder? - Psychology

Figure 1. Panic disorder is a debilitating condition that leaves sufferers with acute anxiety that persists long after a specific panic attack has subsided. When this anxiety leads to deliberate avoidance of particular places and situations a person may be given a diagnosis of agoraphobia. [Image: Nate Steiner, https://goo.gl/dUYWDf, Public Domain]

Have you ever gotten into a near-accident or been taken by surprise in some way? You may have felt a flood of physical sensations, such as a racing heart, shortness of breath, or tingling sensations. This type of physiological reaction is called the fight-or-flight response (Cannon, 1929) and is your body’s natural reaction to fear, preparing you to either fight or escape in response to threat or danger. It is likely you are not too concerned with these sensations because you knew what was causing them. But imagine if this alarm reaction came out of the blue, for no apparent reason, or in a situation in which you did not expect to be anxious or fearful. This sudden onset is considered an unexpected panic attack or a false alarm. Because there is no apparent reason or cue for the alarm reaction, you might react to the sensations with intense fear, maybe thinking you are having a heart attack, going crazy, or even dying. You might begin to associate the physical sensations you felt during this attack with this fear and may start to go out of your way to avoid having those sensations again.


What is a Panic Disorder?

Individuals with Panic Disorder experience more than 1 unexpected full-blown panic attack that are not better explained by medical conditions or substances. This is accompanied by at least a month of persistent worry about subsequent panic attacks and their consequences. They also demonstrate significant maladaptive changes in their behaviour to avoid such panic attacks from occurring, such as avoiding large crowds or avoiding exercise. The frequency of these attacks vary, from short bursts (daily) with long breaks without any attacks, to moderately frequent (once a week), or even low frequency attacks (once a month) over many years.


Management and Treatment

How are panic attacks managed or treated?

Psychotherapy, medications or a combination are very effective at stopping panic attacks. How long you’ll need treatment depends on the severity of your problem and how well you respond to treatment. Options include:

  • Psychotherapy:Cognitive behavioral therapy (CBT) is a type of psychotherapy, or talk therapy. You discuss your thoughts and emotions with a mental health professional, such as a licensed counselor or psychologist. This specialist helps identify panic attack triggers so you can change your thinking, behaviors and reactions. As you start to respond differently to triggers, the attacks decrease and ultimately stop.
  • Antidepressants: Certain antidepressant medications can make panic attacks less frequent or less severe. Providers may prescribe serotonin selective reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs) or tricyclic antidepressants (TCAs). SSRIs include fluoxetine (Prozac®) and paroxetine (Paxil®). SNRIs include duloxetine (Cymbalta®) and venlafaxine (Effexor®). TCAs include amitriptyline (Elavil®) and doxepin (Sinequan®).
  • Anti-anxiety medications: Benzodiazepines are the most commonly prescribed anti-anxiety medication to treat and prevent panic attacks. They help with anxiety but have risks of addiction or dependence. These medications include alprazolam (Xanax®) and lorazepam (Ativan®).

What are the complications of panic attacks?

Panic attacks are highly treatable. Unfortunately, many people put off seeking help because they’re embarrassed. Untreated panic attacks or panic disorder can interfere with your ability to enjoy life. You may develop:

  • Anticipatory anxiety: The possibility of having a panic attack triggers extreme anxiety.
  • Phobias: A phobia is an extreme, unreasonable fear of something specific. For instance, acrophobia is a fear of heights, while claustrophobia is a fear of enclosed spaces.
  • Agoraphobia: Approximately two-thirds of people with panic disorder develop agoraphobia. This anxiety disorder makes you afraid to be in places or situations where a panic attack might happen. The fear can become so extreme that you become too afraid to leave your house.

Chapter

Premium Feature

Description

Psychology Tools for Overcoming Panic takes a cognitive behavioral therapy (CBT) approach to this common anxiety problem. This chapter introduces the stress-vulnerability model of panic and describes: biological and psychological vulnerabilities to panic, stresses and triggers leading to panic, and the intended and unintended consequences of our responses to panic.

Instructions

This is a Psychology Tools workbook chapter. Suggested uses include:

  • Client handout – use as a psychoeducation and skills-development resource
  • Discussion point – use to provoke a discussion and explore client beliefs
  • Therapist learning tool – improve your familiarity with a psychological construct
  • Teaching resource – use as a learning tool during training

References

  • Barlow, D. H. (2004). Anxiety and its disorders: The nature and treatment of anxiety and panic. Guilford press.
  • Clark, D. M. (1986). A cognitive approach to panic. Behaviour research and therapy, 24(4), 461-470.
  • Clark, D. M. (1994). Cognitive therapy for panic disorder. American Psychiatric Association.

> Resources > What Causes Panic? (Psychology Tools For Overcoming Panic)


Physical causes of panic attacks

15. Drinking alcohol

When you drink alcohol, especially a large amount, your physical and mental state changes, and you have less control over your thoughts. While most people will only feel relaxation after a glass of wine, somebody who suffers from anxiety may find that alcohol makes their anxiety worse.

This doesn’t automatically mean you should quit drinking if you’re anxious, but do be aware that it could be a trigger.

16. Doing drugs

Some people who struggle with mental health problems (such as low self-esteem, depression, and of course anxiety) resort to drugs as they think they can eliminate their symptoms temporarily. Of course, that is a terrible solution — get help immediately if you are using drugs, even if “recreationally”.

Believe it or not, many people experience their first attack right after smoking cannabis. Panic is bad enough, but when your mind is in an altered state, it can be the most terrifying thing you could ever experience.

17. Physical exercise

Working out does wonders for all mental health issues. Only, when you exercise:

  • Your heart beats faster
  • Your breathing changes
  • Your body temperature may increase
  • You may feel exhausted

That’s just our body’s natural reaction, however if someone interprets these feelings the wrong way, they may think it’s a panic attack — and experience one.

18. Abrupt posture changes

Much like physical exercise, a sudden change in posture can make you feel different — you may even feel a little dizzy.

The thing is, when you are terrified of having panic attacks, you become hypervigilant. In other words, you notice every single tiny change around you, and every change your body goes through. So something as simple as a posture change could trigger anxiety.

19. Poor diet

Basically, if you are eating the wrong foods, or you aren’t eating enough calories, your body becomes weaker, so it will be more likely to experience headaches or dizziness.

The solution to this is simple: eat enough, eat right, and make sure to drink a lot of water to avoid dehydration. When your mind isn’t in an optimal state, it’s vital to take care of your body.

20. Overeating

Not eating enough calories is usually far worse than overeating, however after a big meal you may notice symptoms such as a faster heart rate, increased body temperature, headaches, nausea, or even anxiety, so it could be a trigger.

However this is just your body having a hard time digesting food, so once again, you need to tell yourself it’s perfectly normal, and not dangerous at all.

21. Breathing too quickly

When you’re anxious, you tend to breathe faster. If you hyperventilate, you may experience dizziness, confusion, or lightheadedness, and you may think you’re about to faint (remember: though it is possible to faint, it’s extremely rare!).

Not surprisingly, some meditation exercises involve long, deep breaths. When you breathe properly, your mind becomes clear, and your whole body relaxes. Whenever you notice you’re more anxious than usual, pay attention to your posture, and the way you breathe: chances are they’re not ideal.

22. Waking up suddenly

Whether it’s because of your alarm clock, a bad dream, or a loud noise, waking up abruptly can cause confusion and a fast heart rate: because you’re disoriented, you may think you are about to experience another panic attack (it happened to me one morning, and I was terrified but like most attacks, it lasted less than five minutes).

Always remind yourself it will be over soon, and accept the fact it’s uncomfortable.

If you suffer from anxiety, it’s important that you eat enough and eat right


SOCIAL ANXIETY DISORDER

Anatomical and Neuroimaging Findings in Social Anxiety Disorder

As with PD and PTSD, amygdala activation has been implicated in symptoms of SAD. Social-cue tasks, such as the viewing of harsh faces, were associated with hyperreactivity in the amygdala and other limbic areas in patients who had SAD. Similarly, in response to viewing negative (but not neutral or positive) affective faces, patients who have SAD exhibited bilateral amygdala activation, which positively correlated with symptom severity and which reversed upon successful treatment. In anticipation of public speaking, subcortical, limbic, and lateral paralimbic activity is increased in patients who have SAD, suggesting elevations in automatic emotional processing. Decreased activity in the ACC and PFC in these subjects suggests a decreased ability for cognitive processing (reviewed in 23 ).

In contrast to the social-cue studies, activity in the left hippocampus and right amygdala was decreased during script-guided mental imagery tasks that provoke social anxiety. This decrease may reflect active blunting of the emotional and autonomic response to improve overall functioning during social situations that provoke anxiety. 106 Furthermore, anxiety-provoking imagery (compared with neutral imagery) was associated with increased activation in the left postcentral gyrus and putamen and in the right inferior frontal and middle temporal gyri. Relative decreased activity was observed in the right middle temporal gyrus, left precuneus, and posterior cingulate gyrus. After 8 weeks of treatment with nefazodone, both remitted and partially improved social anxiety was associated with decreased regional CBF (rCBF) in the lingual gyrus, left superior temporal gyrus, and right vlFC and with increased rCBF in the left middle occipital gyrus and inferior parietal cortex. In subjects who achieved remission following nefazodone treatment, posttreatment testing revealed decreased rCBF in the ventral and dorsal ACC, left vlPFC, dorsolateral PFC, and brainstem and increased rCBF in the middle cingulate cortex, left hippocampus, parahippocampal gyrus, subcallosal orbital, and superior frontal gyri. 106

The combined results of imaging analysis in subjects who have SAD suggest dysfunction of a cortico-striato-thalamic network: hyperactivity in the right PFC, striatal dysfunction, and increased hippocampal and amygdala activity with left lateralization. It has been suggested that hyperactivity in the frontolimbic system, including the ACC, which processes negative emotional information and anticipation of aversive stimuli, could result in misinterpretation of social cues (reviewed in 23,107 ).

Neurotransmitter and Neuroendocrine Signaling in Social Anxiety Disorder

Amino acid neurotransmitters

Increased excitatory glutamatergic activity has been reported in patients who have SAD. Compared with matched control subjects, patients who had SAD had a 13.2% higher glutamate/creatine ratio in the ACC as measured by MRS. The glutamate/creatine ratio correlated with symptom severity, suggesting a causal role between excitatory signaling in the ACC and psychopathology (reviewed in 37 ).

Monoamines

The Neurobiology of Anxiety Disorders In addition to benzodiazepines, SSRIs, SNRIs, and monoamine oxidase inhibitors are effective in the treatment of SAD. That SSRI treatment is successful in treating SAD symptoms and reversing some brain abnormalities (eg, elevated amygdala activity) has been cited as evidence for a serotonergic role in the etiology of SAD. 107 Data supporting the hypothesis of disrupted monoaminergic signaling in patients who have SAD include decreased 5HT1A receptor binding in the amygdala, ACC, insula, and dorsal raphe nucleus (DRN). Moreover, trait and state anxiety is elevated in patients who have SAD who have one or two copies of the short SERT allele, and this patient population exhibits amygdala hyperactivity in anxiety-provocation paradigms. Neuroimaging analyses also have revealed decreased density of the dopamine transporter and decreased binding capacity for the D2 receptor (reviewed in 23 ). A role for DA in SAD is supported by the finding that patients who have Parkinson’s disease have high rates of comorbid SAD (reviewed in 107 ). This co-morbidity, however, could result from insecurity regarding display of the physical symptoms of this movement disorder rather than a common etiology of DA malfunction.

A recent study assessed whether a DA agonist (pramipexole, 0.5 mg) or antagonist (sulpiride, 400 mg) influenced response to anxiogenic challenge such as verbal tasks and autobiographical scripts in patients who had SAD. The anxiogenic effect of the behavioral challenges was significantly increased in patients who had untreated SAD following administration of either drug. After successful treatment with SSRIs, however, administration of pramipexole seemed to dampen the behavioral provocation-induced anxiety, whereas sulpiride administration continued to enhance the anxiogenic effects of these tasks. These authors suggested that instability in the dopaminergic response to social stress contributes to anxiety severity and is normalized only partly by successful treatment, perhaps via SSRI-induced desensitization of postsynaptic D3 receptors. 108

Neuropeptides

As key effectors of social behavior, the neuropeptides oxytocin and vasopressin are of particular interest in SAD and autistic spectrum disorders. Recently direct oxytocin administration to the amygdala in laboratory animals was shown to decrease activation in this region and to dampen amygdala𠄻rainstem communications, which are known to play a role in the autonomic and behavioral components of fear. Furthermore, preliminary data have shown that genetic variants in the central vasopressin and oxytocin receptors (AVP1A and OXTR, respectively) influence amygdalar activity. These data support the hypothesis of amygdala hyperactivity in SAD. Future research in this area may elucidate neural underpinning of human social behavior and the genetic risk for disorders including SAD and autism. 18

Corticotropin-releasing factor and the hypothalamic-pituitary-adrenal axis

Some evidence indicates sensitization of the HPA axis in patients who have SAD. Psychosocial stress produces a greater increase in plasma cortisol, but not ACTH, in patients who have SAD than in control patients despite similar baseline cortisol concentrations. 109 Compared with healthy control subjects or patients who have PTSD, subjects who have SAD tend toward an elevated cortisol response in the Trier Social Stress Test (TSST). The degree of cortisol elevation was correlated with increased avoidance behavior in the approach𠄺voidance task and the predicted stress-induced increased social avoidance above and beyond effects of blood pressure and subjective anxiety. 110 Negative findings also have been reported, however (eg, 111,112 ). For example, an earlier study found that adolescent girls who had social phobia and control subjects exhibited an equal elevation in salivary cortisol following the TSST. To the authors’ knowledge, there are no endocrine-challenge studies (Dex-Suppression, CRF-Stimulation, or Dex/CRF) in patients who have SAD.

Genetic Contribution to Social Anxiety Disorder

The Neurobiology of Anxiety Disorders Unfortunately, there are very few studies specifically examining the genetic underpinnings of SAD. Available data suggest that SAD has a high degree of familial aggregation. In a recent meta-analysis in which SAD was grouped with specific phobia and agoraphobia, an association between phobia in probands and their first-degree relatives was identified. 43

Twin studies in social phobics suggest that additive genetics is responsible for increased incidence of SAD in monozygotic compared with dizigotic twins and suggest no role for common environmental experiences. Adult twin studies of combined phobia diagnoses (including social phobics) suggest that the additive genetics accounts for 20% to 40% of the variance in diagnosis. This result corresponds with a population-based twin study of adolescents diagnosed with social phobia, MDD, and alcoholism, in which genetics accounted for 28% of the risk variance for SAD. Again, the remaining risk was derived from non-shared environmental experiences. Unlike MDD and PTSD, there is little evidence that early-life trauma influences the risk for developing SAD in adulthood. 43

The one genome-wide linkage analysis of SAD implicated a region on chromosome 16 near the gene encoding the norepinephrine transporter. Other genes associated with SAD include (1) a functional variant in ADRB1, the gene encoding the 㬡-adrenergic receptor, and (2) two SNPs and a 3-SNP haplotype in the gene for COMT in female patients who have SAD (reviewed in 107 ). Because SAD is such a complex phenotype, it has been suggested that it may be more fruitful to search for susceptibility genes by examining intermediate phenotypes, quantitative traits, and comorbidity with other illnesses. In fact, SAD heritability includes disorder-specific but also nonspecific genetic factors. SAD is associated with behavioral inhibition in childhood, low extroversion, and high neuroticism. These personality traits are not SAD specific but are hypothesized to contribute to a spectrum of psychopathology inclusive of mood and anxiety disorders. Furthermore, behavioral inhibition, low extroversion, and high neuroticism are each known to be highly heritable and may largely account for the genetic contribution to SAD.

Genes associated with high behavioral inhibition include CRF and SERT. Internalizing neuroticism is associated with the gene encoding glutamic acid decarboxylase, the rate-limiting enzyme in the synthesis of GABA from glutamate (reviewed in 107 ).


SPECIFIC PHOBIA

Phobia is a Greek word that means fear. A person diagnosed with a specific phobia (formerly known as simple phobia ) experiences excessive, distressing, and persistent fear or anxiety about a specific object or situation (such as animals, enclosed spaces, elevators, or flying) (APA, 2013). Even though people realize their level of fear and anxiety in relation to the phobic stimulus is irrational, some people with a specific phobia may go to great lengths to avoid the phobic stimulus (the object or situation that triggers the fear and anxiety). Typically, the fear and anxiety a phobic stimulus elicits is disruptive to the person’s life. For example, a man with a phobia of flying might refuse to accept a job that requires frequent air travel, thus negatively affecting his career. Clinicians who have worked with people who have specific phobias have encountered many kinds of phobias, some of which are shown in [link].

Specific Phobias
Phobia Feared Object or Situation
Acrophobia heights
Aerophobia flying
Arachnophobia spiders
Claustrophobia enclosed spaces
Cynophobia dogs
Hematophobia blood
Ophidiophobia snakes
Taphophobia being buried alive
Trypanophobia injections
Xenophobia strangers

Specific phobias are common in the United States, around 12.5% of the population will meet the criteria for a specific phobia at some point in their lifetime (Kessler et al., 2005). One type of phobia, agoraphobia , is listed in the DSM-5 as a separate anxiety disorder. Agoraphobia, which literally means “fear of the marketplace,” is characterized by intense fear, anxiety, and avoidance of situations in which it might be difficult to escape or receive help if one experiences symptoms of a panic attack (a state of extreme anxiety that we will discuss shortly). These situations include public transportation, open spaces (parking lots), enclosed spaces (stores), crowds, or being outside the home alone (APA, 2013). About 1.4% of Americans experience agoraphobia during their lifetime (Kessler et al., 2005).


Answers to Your Questions About Panic Disorder

Panic Disorder is a serious condition that around one out of every 75 people might experience. It usually appears during the teens or early adulthood, and while the exact causes are unclear, there does seem to be a connection with major life transitions that are potentially stressful: graduating from college, getting married, having a first child, and so on. There is also some evidence for a genetic predisposition if a family member has suffered from panic disorder, you have an increased risk of suffering from it yourself, especially during a time in your life that is particularly stressful.

A panic attack is a sudden surge of overwhelming fear that comes without warning and without any obvious reason. It is far more intense than the feeling of being "stressed out" that most people experience. Symptoms of a panic attack include:

difficulty breathing, feeling as though you "can't get enough air"

terror that is almost paralyzing

dizziness, lightheadedness or nausea

trembling, sweating, shaking

hot flashes, or sudden chills

tingling in fingers or toes ("pins and needles")

fear that you're going to go crazy or are about to die

You probably recognize this as the classic "flight or fight" response that human beings experience when we are in a situation of danger. But during a panic attack, these symptoms seem to rise from out of nowhere. They occur in seemingly harmless situations--they can even happen while you are asleep.

In addition to the above symptoms, a panic attack is marked by the following conditions:

it occurs suddenly, without any warning and without any way to stop it.

the level of fear is way out of proportion to the actual situation often, in fact, it's completely unrelated.

it passes in a few minutes the body cannot sustain the "fight or flight" response for longer than that. However, repeated attacks can continue to recur for hours.

A panic attack is not dangerous, but it can be terrifying, largely because it feels "crazy" and "out of control." Panic disorder is frightening because of the panic attacks associated with it, and also because it often leads to other complications such as phobias, depression, substance abuse, medical complications, even suicide. Its effects can range from mild word or social impairment to a total inability to face the outside world.

In fact, the phobias that people with panic disorder develop do not come from fears of actual objects or events, but rather from fear of having another attack. In these cases, people will avoid certain objects or situations because they fear that these things will trigger another attack.

Please remember that only a licensed therapist can diagnose a panic disorder. There are certain signs you may already be aware of, though.

One study found that people sometimes see 10 or more doctors before being properly diagnosed, and that only one out of four people with the disorder receive the treatment they need. That's why it's important to know what the symptoms are, and to make sure you get the right help.

Many people experience occasional panic attacks, and if you have had one or two such attacks, there probably isn't any reason to worry. The key symptom of panic disorder is the persistent fear of having future panic attacks. If you suffer from repeated (four or more) panic attacks, and especially if you have had a panic attack and are in continued fear of having another, these are signs that you should consider finding a mental health professional who specializes in panic or anxiety disorders.

Body: There may be a genetic predisposition to anxiety disorders some sufferers report that a family member has or had a panic disorder or some other emotional disorder such as depression. Studies with twins have confirmed the possibility of "genetic inheritance" of the disorder.

Panic Disorder could also be due to a biological malfunction, although a specific biological marker has yet to be identified.

All ethnic groups are vulnerable to panic disorder. For unknown reasons, women are twice as likely to get the disorder as men.

Mind: Stressful life events can trigger panic disorders. One association that has been noted is that of a recent loss or separation. Some researchers liken the "life stressor" to a thermostat that is, when stresses lower your resistance, the underlying physical predisposition kicks in and triggers an attack.

Both: Physical and psychological causes of panic disorder work together. Although initially attacks may come out of the blue, eventually the sufferer may actually help bring them on by responding to physical symptoms of an attack.

For example, if a person with panic disorder experiences a racing heartbeat caused by drinking coffee, exercising, or taking a certain medication, they might interpret this as a symptom of an attack and, because of their anxiety, actually bring on the attack. On the other hand, coffee, exercise, and certain medications sometimes do, in fact, cause panic attacks. One of the most frustrating things for the panic sufferer is never knowing how to isolate the different triggers of an attack. That's why the right therapy for panic disorder focuses on all aspects -- physical, psychological, and physiological -- of the disorder.

The answer to this is a resounding YES -- if they receive treatment.

Panic disorder is highly treatable, with a variety of available therapies. These treatments are extremely effective, and most people who have successfully completed treatment can continue to experience situational avoidance or anxiety, and further treatment might be necessary in those cases. Once treated, panic disorder doesn't lead to any permanent complications.

Without treatment, panic disorder can have very serious consequences.

The immediate danger with panic disorder is that it can often lead to a phobia. That's because once you've suffered a panic attack, you may start to avoid situations like the one you were in when the attack occurred.

Many people with panic disorder show "situational avoidance" associated with their panic attacks. For example, you might have an attack while driving, and start to avoid driving until you develop an actual phobia towards it. In worst case scenarios, people with panic disorder develop agoraphobia -- fear of going outdoors -- because they believe that by staying inside, they can avoid all situations that might provoke an attack, or where they might not be able to get help. The fear of an attack is so debilitating, they prefer to spend their lives locked inside their homes.

Even if you don't develop these extreme phobias, your quality of life can be severely damaged by untreated panic disorder. A recent study showed that people who suffer from panic disorder:

are more prone to alcohol and other drug abuse

have greater risk of attempting suicide

spend more time in hospital emergency rooms

spend less time on hobbies, sports and other satisfying activities

tend to be financially dependent on others

report feeling emotionally and physically less healthy than non-sufferers

are afraid of driving more than a few miles away from home

Panic disorders can also have economic effects. For example, a recent study cited the case of a woman who gave up a $40,000 a year job that required travel for one close to home that only paid $14,000 a year. Other sufferers have reported losing their jobs and having to rely on public assistance or family members.

None of this needs to happen. Panic disorder can be treated successfully, and sufferers can go on to lead full and satisfying lives.

Most specialists agree that a combination of cognitive and behavioral therapies are the best treatment for panic disorder. Medication might also be appropriate in some cases.

The first part of therapy is largely informational many people are greatly helped by simply understanding exactly what panic disorder is, and how many others suffer from it. Many people who suffer from panic disorder are worried that their panic attacks mean they're "going crazy" or that the panic might induce a heart attack. "Cognitive restructuring" (changing one's way of thinking) helps people replace those thoughts with more realistic, positive ways of viewing the attacks.

Cognitive therapy can help the patient identify possible triggers for the attacks. The trigger in an individual case could be something like a thought, a situation, or something as subtle as a slight change in heartbeat. Once the patient understands that the panic attack is separate and independent of the trigger, that trigger begins to lose some of its power to induce an attack.

The behavioral components of the therapy can consist of what one group of clinicians has termed "interoceptive exposure." This is similar to the systematic desensitization used to cure phobias, but what it focuses on is exposure to he actual physical sensations that someone experiences during a panic attack.

People with panic disorder are more afraid of the actual attack than they are of specific objects or events for instance, their "fear of flying" is not that the planes will crash but that they will have a panic attack in a place, like a plane, where they can't get to help. Others won't drink coffee or go to an overheated room because they're afraid that these might trigger the physical symptoms of a panic attack.

Interoceptive exposure can help them go through the symptoms of an attack (elevated heart rate, hot flashes, sweating, and so on) in a controlled setting, and teach them that these symptoms need not develop into a full-blown attack. Behavioral therapy is also used to deal with the situational avoidance associated with panic attacks. One very effective treatment for phobias is in vivo exposure, which is in its simplest terms means breaking a fearful situation down into small manageable steps and doing them one at a time until the most difficult level is mastered.

Relaxation techniques can further help someone "flow through" an attack. These techniques include breathing retraining and positive visualization. Some experts have found that people with panic disorder tend to have slightly higher than average breathing rates, learning to slow this can help someone deal with a panic attack and can also prevent future attacks.

In some cases, medications may also be needed. Anti-anxiety medications may be prescribed, as well as antidepressants, and sometimes even heart medications (such as beta blockers) that are used to control irregular heartbeats.

Finally, a support group with others who suffer from panic disorder can be very helpful to some people. It can't take the place of therapy, but it can be a useful adjunct.

If you suffer from panic disorder, these therapies can help you. But you can't do them on your own all of these treatments must be outlined and prescribed by a psychologist or psychiatrist.

Much of the success of treatment depends on your willingness to carefully follow the outlined treatment plan. This is often multifaceted, and it won't work overnight, but if you stick with it, you should start to have noticeable improvement within about 10 to 20 weekly sessions. If you continue to follow the program, within one year you will notice a tremendous improvement.

If you are suffering from panic disorder, you should be able to find help in your area. You need to find a licensed psychologist or other mental health professional who specializes in panic or anxiety disorders. There may even be a clinic nearby that specializes in these disorders.

When you speak with a therapist, specify that you think you have panic disorder, and ask about his or her experience treating this disorder.

Keep in mind, though, that panic disorder, like any other emotional disorder, isn't something you can either diagnose or cure by yourself. An experience clinical psychologist or psychiatrist is the most qualified person to make this diagnosis, just as he or she is the most qualified to treat this disorder.

This brochure is designed to answer your basic questions about panic disorder a qualified mental health professional will be able to give you more complete information.

Panic disorder does not need to disrupt your life in any way!