Panic Disorder DSM-5 300.01 (F41.0)
DSM-5 Category: Anxiety Disorders
Introduction
The DSM-5 describes a panic attack as “an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes.” (American Psychiatric Association, 2013). These attacks are recurrent and unanticipated by the patient. Panic disorder can cause a variety of interpersonal and occupational problems. Individuals with recurrent panic may avoid social situation or going out in public altogether. These patients try to avoid a potentially embarrassing attack. This can lead to withdrawal from friends and family; and absence from work and school. Thankfully, panic disorder can be treated. Dialectical behavior therapy is among most effective treatments for panic disorder (American Psychiatric Association, 2013).
Symptoms of Panic Disorder
According to the DSM-5, the most prominent diagnostic criterion for panic disorder is recurrent unexpected panic attacks. Because the panic attacks are unexpected, they are impossible to predict, and the patient usually feels that they “come out of the blue.” This surge of fear can occur during a time of existing anxiety but can also begin during calm state, such as while relaxing, sleeping or while engaging in an enjoyable activity. Common features of panic attacks include an accelerated heart rate or pounding heart beats, chest pain, sweating, trembling, shortness of breath, a choking sensation, nausea, dizziness or light-headedness ,numbness, chills or heat, a feeling of being detached from one’s self, fear of losing control and fear of dying. In addition to these attacks, the patient experiences persistent worry or fear of having a panic attack and often changes behaviors and routines to avoid panic attacks. These symptoms are not related to substance use, or other medical or psychiatric condition (American Psychiatric Association, 2013).
Social Issues
People who experience unexpected panic attacks often become fearful of experiencing a sudden panic attack at work, with friends, or in public. They are concerned that they may be judged for their behavior or lose control; resulting in perceived embarrassment. These fears often lead people to change their habits in order to avoid a public panic attack. For example, a woman with recurrent panic attacks may stop taking public transportation, stop going to the gym and stop attending church. She may decline invitations to parties and other events. People who suffer from frequent panic attacks may miss work or school. This can lead to social isolation, causing feelings of sadness and problems within relationships. Friends and family members may be affected by these changes in social behavior (American Psychiatric Association, 2013).
Additionally, the physical symptoms of panic attacks often lead patients to be concerned about illness or acute medical conditions (American Psychiatric Association, 2013). Symptoms such as chest pain, heart palpitations, and faintness can closely mimic the symptoms of serious cardiac conditions. Many patients with panic disorder are first diagnosed when they seek emergency care for what they believe is a heart attack. In fact, the majority of noncardiac chest without medical cause is attributed to anxiety and panic (Achiam-Montal, Tibi & Lipsitz, 2013). Patients who suffer from asthma are also at increased risk for panic disorder. Sometimes, patients who suffer from recurrent panic attacks turn to drugs or alcohol to manage symptoms. Several medications are useful in managing panic disorder, but they are often highly addictive (American Psychiatric Association, 2013).
Risk Factors
In the United States and Europe, the prevalence of panic disorder is between 2% and 3% for adults and adolescents. According to the DSM-5, several risk factors have been identified. Temperament is one well-documented risk factor of panic disorder. Individuals who experience anxiety or have a history of being fearful are at increased risk of developing panic disorder. Environmental risk factors are also common. People who experience childhood physical or sexual abuse are at increased risk for developing panic disorder (American Psychiatric Association, 2013). Recent studies examining twins estimate that the heritability of panic disorder is 30-40% (Spatola, et al., 2011). Although no specific gene related to panic disorder has been indentified, the DSM-5 explains that multiple genes may make individuals particularly sensitive to panic. Individuals whose parents experienced depression, anxiety or bipolar disorder are at an increased risk of developing panic disorder (American Psychiatric Association, 2013).
Treatment of Panic Disorder
Although medications exist to ease anxiety and reduce panic attack, they are largely ineffective without therapy. Dialectical Behavioral Therapy consists of individual therapy, group therapy, and telephone consultation. During individual therapy, the patient can work on skills to overcome interpersonal problems that may lead to anxiety; as well as skills for reducing and dealing with panic attacks. In group therapy, the patient can discuss current problems with others who are experiencing similar challenges. Dialectical behavior therapy patients have access to call their therapist at any time. This is helpful for getting through crisis situations such as a sudden, unexpected panic attack (Chapman, et al., 2011).
Several important skills are strengthened during each component of dialectical behavioral therapy. Mindfulness skills help patients to live in the “here and now” and focus on present experiences. Emotion regulation skills help the patient to indentify emotions and reduce feelings that create vulnerability to anxiety. Interpersonal skills help patients related to others in a healthy way. Many times, recurrent panic leads patients to fear social situation. Distress tolerance skills help patients deal with crisis as well as overwhelming situations and emotional states. Dialectical behavior theory places a strong emphasis on balance. In most cases, this is a balance between acceptance and change. Change can be very difficult, even threatening to those who suffer from panic disorder. Accepting panic can help the patient focus on other issues that may create the panic (Chapman, et al., 2011).
Treating panic disorder in children is similar to treating panic disorder in adults. However, the addition of family therapy is an important component. In family therapy, the child’s parents or primary caregiver can become educated about panic disorder and the child’s treatment plan. When parents are cooperative with the plan, treatment outcomes are more successful. Because children do not actively seek treatment, they may be resistant or less cooperative than patients who seek out their own treatment. Creating a positive therapeutic alliance among parents, therapist and child is the best way to motivate a child to participate in the therapy process (Beidel & Alfano, 2011).
References
Achiam-Montal, M., Tibi, L. & Lipsitz, J.D. Panic disorder in children and adolescents with noncardiac chest pain. Child Psychiatry and Human Development. 44(6): 742-50
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Beidel, D.C. &Alfano, C.A. Child anxiety disorder: A guide to research and treatment. New York: Routledge.
Chapman, A., Gratz, K., Tull, M. & Keane, T. (2011). The dialectical behavior therapy skills workbook for anxiety : Breaking free from worry, panic, PTSD, and other anxiety symptoms. Oakland: New Harbinger Publications.
Spatola, C.A.M., Scaini, S., Pesenti-Gritti, P., Medland, S.E., Moruzzi, S., Ogliari, A., Tambs, K., Battaglia, M. (2011). Gene-environment interactions in panic disorder and CO₂ sensitivity: Effects of events occurring early in life. American Journal of Medical Genetics Part B: Neuropsychiatric Genetics, 156(1): 79-88
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