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- A classic panic attack that is characterized by rapid onset of a brief period of sympathetic nervous system hyperarousal accompanied by intense fear
- In panic disorder, multiple panic attacks occur (including at least two without a recognizable trigger). Patients experience at least 1 month of worried anticipation of additional attacks and/or maladaptive (e.g., avoidance) behaviors.
- Predominant age: all ages; in school-aged children, panic disorder can be confused with conduct disorder and school avoidance.
- Median age of onset 24 years. Prevalence significantly decreases after 60 years.
- Predominant sex: female > male (2:1)
- Lifetime prevalence: 4.7%
- 4–8% of patients in a primary care practice population have panic disorder.
- Of patients presenting with chest pain in the emergency room, 25% have panic disorder.
- Chest pain is more likely due to panic if atypical, younger age, female, and known problems with anxiety.
Etiology and Pathophysiology
- Biologic theories focus on limbic system malfunction in dealing with anxiety-evoking stimuli.
- Psychological theories posit deficits in managing strong emotions such as fear and anger.
- Patients resist the initial surge of adrenaline which exacerbates the symptoms—in essence, they get anxious about being anxious. Concerns about a dangerous cause of symptoms and worries about going crazy or losing control also exacerbate symptoms.
- Noradrenergic neurotransmission from the locus coeruleus causes increased sympathetic stimulation throughout the body.
- Current neurobiologic research focuses on abnormal responses to anxiety-producing stimuli in the hippocampus, amygdala, and prefrontal cortex; for example, there appears to be limbic kindling in which an original frightening experience dominates future responses even when subsequent exposures are not objectively threatening.
- Brain pH disturbances (e.g., excess lactic acid) from normal mentation in genetically vulnerable patients may activate the amygdala and generate unexpected fear responses.
- Twin studies have suggested a heritability of approximately 40% with contributions of 10% from common familial environment and >50% from individual-specific environmental effects. Some monoamine-related genes, such as serotonin transporter and monoamine oxidase A genes, have been proven to play a role in panic disorder.
- Life stressors of any kind can precipitate attacks.
- History of sexual or physical abuse; anxious, overprotective parents
- Substance abuse, bipolar disorder, major depression, obsessive-compulsive disorder (OCD), and simple phobia
Commonly Associated Conditions
- Of patients with panic disorder, >70% also have ≥1 other psychiatric diagnoses: PTSD (recalled trauma precedes panic attack), social phobia (fear of scrutiny precedes panic attack), simple phobia (fear of something specific precedes panic), major depression, bipolar disorder, substance abuse, OCD, separation anxiety disorder.
- Panic disorder is more common in patients with asthma, migraine headaches, hypertension, mitral valve prolapse, reflux esophagitis, interstitial cystitis, irritable bowel syndrome, fibromyalgia, nicotine dependence.
- Panic disorder increases the risk of suicide attempts and ideation.