Title: Panic Disorder
Authors: Harith Al-Azzawi, Ghadeer Al-Qaq
Editor: Fadlullah M. F. Al-Saleem
Reviewer: Philip J. Sweidan
Keywords: Antidepressants, CBT, Cognitive Behavior Therapy, Panic Attack, Panic Disorder.
Panic disorder is a prevalent mental illness that affects up to 5% of the population at some time in their lives. It is frequently debilitating, especially when accompanied by agoraphobia, and is associated with significant functional morbidity and worse quality of life. The condition is also expensive for people and society, as seen by higher healthcare utilization, absenteeism, and decreased workplace productivity. Some medical conditions (for example, asthma) are frequently associated with panic disorder, and some lifestyle variables (for example, smoking) enhance the risk for the disorder, although the causative pathways are yet unknown. There are additional genetic and early experience susceptibility factors, although their exact nature and pathophysiological processes are unclear. Despite an incomplete, but growing, understanding of the etiology, significant evidence supports the use of various successful therapies (For example, pharmaceutical, cognitive-behavioral). The adaption and diffusion of these therapies to the frontlines of medical care should be top priorities for the public health community.
According to the DSM-5, panic disorder is recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak level within minutes.
It is a common mental disorder that affects up to 5% of the population at a point in life. It can be disabling especially when complicated by agoraphobia, which is associated with substantial functional morbidity and reduced life quality. This disorder is costly for individuals and society, as shown by increased use of health care, absenteeism, and reduced workplace productivity. 
The exact cause of panic disorder has not been determined, although some factors can play a role in this disorder such as family history, drug abuse, brain abnormalities, and stress are some of the factors that can trigger panic attack episodes attributed to this disorder. 
The central nervous system’s neurotransmitters and peptides appear to have a vital influence on physical symptoms. Brain imaging studies have revealed distinct alterations in certain geographic locations, such as the limbic and frontal regions, including enhanced flow and receptor activity. The amygdala is thought to be the primary source of malfunction.Medical sickness and panic disorder are highly connected from a pathophysiological and psychological standpoint. Two basic theories try to explain why patients are more prone to panic episodes. The first hypothesis proposes that vulnerable patients lack the neurochemical mechanisms that would usually regulate serotonin and that this elevated serotonin produces changes in the autonomic nervous system’s fear network model. 
Presentation and Diagnosis
Panic disorder is characterized by episodic, unexpected attacks that occur with no obvious trigger, although many patients with this disorder have expected panic attacks, to occur in response to a known trigger. The most common physical symptom occurring with panic attacks is palpitations. 
Below are 13 symptoms in which four or more occur combined and they are :
- Accelerated heart rate.
- Shaking or trembling.
- Shortness of breath.
- The feeling of choking.
- Chest pain and discomfort.
- Abdominal distress
- Feeling light-headed, dizzy, unsteady, or faint.
- A sensation of chills or heat.
- Paresthesias (tingling or numbness).
- Depersonalization (being detached from oneself) or derealization (feelings of unreality).
- Losing control.
- Fear of death.
The frequency of panic attacks varies widely. There may be moderately frequent attacks; for months at a time, or short bursts of more frequent attacks separated by weeks or months without any attacks or with less frequent attacks over many years. In terms of severity, individuals with panic disorder may have both full-symptom attacks, which include four or more symptoms, and limited-symptom attacks, which include fewer than four symptoms. The type and number of symptoms differ from one panic attack to the other. However, more than one unexpected full-symptom panic attack is necessary for the diagnosis. 
Symptoms of the disorder often start late in teens or in early adulthood and affect women more than men. Many factors may increase the risk of developing panic attacks or panic disorder including: 
- Familial history of panic attacks or disorder
- Major life stress, such as a loved one’s death or critical illness
- A traumatic occurrence, such as sexual assault or a serious automobile accident
- Significant life events, such as a divorce or the birth of a child
- Smoking or excessive caffeine use
- A history of physical or sexual abuse as a child
Panic disorder is a chronic condition with a wide range of symptoms. In more than 85 percent of instances, appropriate pharmacologic therapy and cognitive-behavioral therapy (CBT), either alone or in combination, are beneficial. Patients with good premorbid functioning and symptoms that last for a short time have a better prognosis. Approximately 10-20% of people continue to experience substantial symptoms.
Overall, the long-term prognosis for panic disorder is generally favorable, with over 65 percent of patients experiencing remission within six months. However, as discussed under History, trigger factors can cause panic attacks; several of these triggers have been linked to poor outcomes, including severe illness at the time of the initial assessment, high interpersonal sensitivity, low social class, separation from a parent due to death when young, divorce, and single status. 
Patients with panic disorder have a significantly increased incidence of coronary artery disease. Panic can cause myocardial ischemia in patients with coronary artery disease. Reduced heart rate variability and increased QT interval variability may theoretically raise the risk of sudden death. 
Individuals with panic disorder have a suicide rate that is many times greater than the overall population. 
In general, panic disorder can be treated effectively with pharmacological and psychological treatments, like cognitive-behavioral therapy and mindfulness interventions. 
Although pharmacological treatments are proven to be potent in panic disorder therapy, their potential side effects can be obstacles to binding to treatment and the long-term maintenance of achieved treatment goals. So, providing effective psychological interventions is important for this disorder either as a supportive or stand-alone treatment. However, the availability of treatment places is limited to conventional face-to-face mental health centers. 
Various effective medications are available for treating this disorder, but results have been unsatisfactory in some patients, suggesting the effectiveness of expanding the array of anti-panic medications and improving the quality of response to currently recommended treatments. 
Treatment choices are listed below:
Antidepressant medications have proved to reduce panic attack severity, eliminate attacks, and improve the overall life quality measures in patients with panic disorder. 
Two recent meta-analyses , found that TCAs (tricyclic antidepressants) and SSRIs (selective serotonin reuptake inhibitors) are effective equally in reducing the number and severity of the attacks. The choice of antidepressant medication should be based on the patient’s choices according to side effect profiles. MAO inhibitors (Monoamine oxidase inhibitors) also are effective in the treatment of panic disorders, but their use is limited due to safety concerns. 
Benzodiazepines have been proven to be useful in the treatment of various forms of anxiety for decades. These anxiety expressions have recently been separated into categories and diseases, such as generalized anxiety disorder and panic disorder.  The use and efficacy of benzodiazepine receptor agonists in individuals with these different diagnoses have been explored by researchers. Clinical research on generalized anxiety disorder and panic disorder typically shows that benzodiazepine agonists have similar efficacy, while true comparison studies with two or three medications are rare. The differences in side effects, pharmacokinetics, and withdrawal reactions for benzodiazepines require more research. Concerns regarding benzodiazepine reliance, whether justified or not, and cessation effects have prompted researchers to look for novel benzodiazepines that do not have these issues. This study addresses recent breakthroughs in research on novel benzodiazepine compounds and reviews the efficacy and comparative studies of benzodiazepines that are already accessible. 
Along with drug therapy for panic disorder, neuromodulation techniques including TMS (Transcranial Magnetic stimulation) are used in panic disorder with varying results. 
- Cognitive Behavior Therapy
Cognitive behavior therapy (CBT) includes many techniques, for instance, exposure in vivo, applied relaxation, panic management, exposure through imagery, breathing retraining, and cognitive restructuring. Meta-analyses encourage the efficacy of CBT in relieving panic symptoms and overall disability.
It’s uncertain if cognitive treatment (e.g., detecting mistaken feelings, educating patients about panic episodes) or behavior therapy is more important in CBT (e.g., breathing exercises, exposure, relaxation). However, in patients with panic disorder, particularly in patients with agoraphobia, the efficacy of exposure approaches alone, in which the patient repeatedly encounters the anxiety-provoking stimulus through visualization or in vivo, is well documented. Referral to an expert exposure therapist is suggested whenever possible. 
Some panic disorder sufferers, especially men, self-medicate with alcohol, which interferes with therapy. In a single trial of people with alcohol addiction with panic disorder, adding CBT to an alcohol treatment program had no more effect on reducing panic symptoms than alcohol therapy alone. 
There is no guarantee that panic episodes or panic disorders will not occur. However, these suggestions might be useful:
- To prevent panic attacks from getting worse or becoming more common, seek treatment as soon as feasible.
- To avoid relapses or worsening panic attack symptoms, stick to your treatment plan.
- Maintain a regular physical activity regimen, which may help to reduce anxiety. 
Panic disorder is a common condition with an unclear origin. To begin adequate therapy, the disease must be detected early. There are two methods of therapy that are indicated. One or both are chosen based on the patient’s desire and the intensity of the panic attack. CBT is typically the first-line treatment for panic disorder, followed by at least a year of antidepressant medication. Patients suffering from this disease should be provided counseling to help them overcome their concerns. It is vital to consult a psychologist regularly to ensure that the panic attack is under control.
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