Panic Disorder & Agoraphobia

Panic Disorder & Agoraphobia
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Describe the features of panic disorder, with or without agoraphobia, and discuss the biological and cognitive explanations and therapies of this disorder.

Panic disorder is classified as an anxiety disorder in The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) by the American Psychiatric Association (APA) is the system used in the United States to diagnose mental health disorders. The DSM contains diagnostic criteria used by mental health professionals to classify and describe every mental illness. According to the guidelines, in order to be diagnosed with a panic disorder, one must experience an unexpected panic attacks on a regular basis. In addition to that, at least one attack is followed by one month or more of the person fearing that they will have more attacks. It’s important that in order to diagnose panic disorder, any other underlying medical condition, for example heart issues, endocrine condition like hyperthyroidism, any substance abuse issues (like THC, stimulants like cocaine, amphetamine and methamphetamine, LSD and ecstasy and withdrawal from benzodiazepines and opiates analgesic) must be ruled out. The attacks are not due to the direct physiological effects of a substance (such as drug use or a medication) or a general medical condition. Also, the attacks are not better accounted for by another mental disorder. These may include a social phobia or another specific phobia, obsessive-compulsive disorder, post-traumatic stress disorder, or separation anxiety disorder (Goodwin, 2015). Goodwin (2015) found “the various anxiety disorders are highly comorbid with each other. For instance, using lifetime diagnoses in the US population data, 74.1% of those with agoraphobia, 68.7% of those with simple phobia, and 56.9% of those with social phobia also met criteria for another anxiety disorder”.

 Panic attacks are key to a panic disorder diagnosis, they are well defined and rather specific.

According to DSM-5, a panic attack is characterized by four or more of the following symptoms Black and Grant, 2014, p. 137):

  • Palpitations, pounding heart, or accelerated heart rate
  • Sweating
  • Trembling or shaking
  • Sensations of shortness of breath or smothering
  • A feeling of choking
  • Chest pain or discomfort
  • Nausea or abdominal distress
  • Feeling dizzy, unsteady, lightheaded, or faint
  • Feelings of unreality (derealization) or being detached from oneself (depersonalization)
  • Fear of losing control or going crazy
  • Fear of dying
  • Numbness or tingling sensations (paresthesia)
  • Chills or hot flushes

The presence of fewer than four of the above symptoms may be considered a limited-symptom panic attack.

The diagnostic criteria for agoraphobia includes the experience of intense fear or anxiety in at least two agoraphobic situations, such as being outside the home alone, public transportation (i.e. airplanes, buses, subways, etc.), open spaces, public places (i.e. stores, theaters, or cinemas), crowds or standing in a line with other people, or a combination of two or more of these scenarios. To be diagnosed with agoraphobia, the person will also need to be exhibiting avoidance behaviors. Agoraphobia tend to be pervasive and complex. It typically develops in 20s or 30s and 13.3% of the U.S. population suffers from agoraphobia (Bystritsky, Khalsa, Cameron and Schiffman, 2013) with the lifetime prevalence of 4.7% in U.S. (Kessler et al., 2005). Patients with agoraphobia display symptoms that usually continue for 6 months or more and cause significant distress and impairment. Many people with agoraphobia also experience extreme panic attacks and that those individuals are diagnosed with both agoraphobia and panic disorder.

Cognitive theory for panic disorder rests on the fact that full panic reactions are experienced only by people who misinterpret bodily events and they are more sensitive to certain bodily sensations and may misinterpret them as signs of a medical urgencies (Comer, 2010, p. 160). These are the individuals who have experienced more trauma-filled events and they experience more intense and extreme bodily sensations.

Biologically perspective of the panic disorder relies on the fact that different neurotransmitters like GABA, norepinephrine, serotonin have been implicated and different brain structures like Amygdala and Locus Coeruleus have been found in the studies to play a role in the pathogenesis of panic disorder. Also, patients with positive family history of panic disorder are at higher risk (Bystritsky, Khalsa, Cameron and Schiffman, 2013; Goodwin, 2015).

Cognitive behavioral therapy and the pharmacotherapy are the cornerstone for the treatment of panic disorder with or without agoraphobia (Bystritsky, Khalsa, Cameron and Schiffman, 2013). Cognitive therapy tries to correct people’s misinterpretations of their bodily sensations and also help them practice coping strategies and making more accurate interpretations.  Medicines like Antidepressants (in the past tricyclics were more popular but because of side effects they have been replaced by newer SSRI’s; selective serotonin reuptake inhibitors) and medicines from Benzodiazepines family are helpful. Antidepressants are for long term or chronic use and they take few weeks have the optimum therapeutic effect. On the other end, benzodiazepines are quick and fast acting and help with the symptoms and are frequently employed in the emergency room setting for quick relief as the patients with the panic attacks usually end up in the ER as if they are having a heart attack, stroke and frequently describe having a nervous breakdown or meltdown feelings but the benzodiazepines do carry the risk of abuse, dependence and withdrawals which can be life threatening (Hawryluk, 2014). In summary, both cognitive behavioral therapy and medicines have a role in the treatment of panic disorder with or without agoraphobia.

References

American Psychiatric Association. (2012). Diagnostic and Statistical Manual of Mental Disorders (Fifth ed.). Washington DC: Amer Psychiatric Pub Inc.

Black, D. W. and Grant, D. W. (2014). DSM-5® Guidebook The Essential Companion to the Diagnostic and Statistical Manual of Mental Disorders (Fifth ed.). Washington DC: American Psychiatric Publishing.

Bystritsky, A., Khalsa, S. S., Cameron, M. E., & Schiffman, J. (2013). Current Diagnosis and Treatment of Anxiety Disorders. Pharmacy and Therapeutics38(1), 30–57.

Comer, R.J. (2010). Abnormal psychology (9th ed.). New York, NY: Worth.

Goodwin, G. M. (2015). The overlap between anxiety, depression, and obsessive-compulsive disorder. Dialogues in Clinical Neuroscience17(3), 249–260.

Hawryluk, M. (2014, June 01). Benzodiazepines treat anxiety, cause long-term problems: Meant for short-term relief, these medications are prescribed repeatedly. Retrieved from The Bulletin: http://www.bendbulletin.com/localstate/2119922-151/benzodiazepines-treat-anxiety-cause-long-term-problems

Kessler. R. C., Berglund, P.,  Demler, O., Jin, R. Merikangas, K. R. and Walters, E. E. (2005). Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry, 62(6), 593-602. doi:10.1001/archpsyc.62.6.593