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Panic Disorder With and Without Agoraphobia

The symptoms of a panic attack are very similar to those of a heart attack: the heart pounds, breathing is almost impossible and people believe that death is imminent or that they are going crazy.

A panic attack can happen anytime and anywhere without any warning sign: this can be while you are relaxing, sleeping, walking the dog, dining out with good friends, etc. Most people experience this kind of panic attack disorder once in their lifetimes; some others have it sometimes twice and the episode is ‘forgotten’ for them.

Panic Disorder With and Without Agoraphobia

More unfortunate people who suffer from recurrent panic attacks develop over time a never-ending fear of having another panic attack. They simply cannot forget the terrible intense fear that they have felt during their panic attack, and their self-confidence vanishes with time. This fear of fear is practically always present with them and usually influences negatively the person’s daily activities and quality of life.

These people are said to suffer from a condition called panic attack disorder (or panic disorder) which can be extremely disabling and eventually lead to typical panic disorder symptoms.

Some other people simply refuse to leave their place or do everything possible not to find themselves in situations that have once triggered their panic attacks.

People who have ever experienced a panic attack are said to be at greater risk for having subsequent panic attacks than those who have never had to stand a panic attack. Despite the fact that a panic attack disorder can affect seriously a person’s quality of life, it can be treated very effectively.

What is a panic attack?

A panic attack is a sudden and terrific episode of overwhelming fear, nervousness, and anxiety that strikes severe physical and emotional reactions out of the blue without any apparent reason or cause – although there is no actual danger – that announces the occurrence of the panic attack. Each panic attack can be awfully frightening for the person who experiences it.

Symptoms of a panic attack

A panic attack typically strikes out of the blue, without any warning, and mostly without any clear reason. A panic attack can occur anywhere and anytime: while driving, flying, discussing with friends or business partners, relaxing on your sofa, etc.

Panic attack symptoms usually develop instantaneously, mostly reach their peak within the next 10 minutes, and usually last for 20 to 30 minutes.

Most people suffering from a panic attack disorder generally experience a few or a combination of the following panic disorder symptoms:
  • losing control,
  • experiencing impending doom or danger,
  • sweating,
  • trembling,
  • having chest pains,
  • headache,
  • dizziness,
  • faintness,
  • chills,
  • hyperventilation,
  • nausea hot flashes,
  • abdominal cramping, etc.

Panic disorder

The most terrible thing people experience after their first panic attack is by far the intense fear of having to re-experience another panic attack, i.e. to suffer from a real panic attack disorder (or panic disorder).

People suffering from a panic attack disorder always do their utmost to avoid objects or situations likely to trigger a new panic attack. In some cases, people may even not be capable of leaving their homes; they do not feel safe in any other place. These people are said to develop a so-called phobic avoidance that makes them avoid certain places, environments, or situations.

Panic Attack Prevalence

In the United States, an estimated 4.7% of adults experience panic disorder at some time in their lives. [Source: NIMH]

People who suffer from panic attacks are reported to consult about a dozen of doctors before they receive a correct diagnosis and can start being treated adequately for their actual panic attack symptoms.

Women are usually at risk to be up to three times more often affected by a panic attack than men.

People with low education and/or low household income are also usually more affected by panic attacks than married people or people living with a partner.

The most common age to experience the first panic attack is late adolescence and mid-thirties

Symptoms of panic disorder

The vast majority of people experience, fortunately ‘only’ one or two panic attacks without complications in their lifetime. The problem with some of those people who have had panic attacks is that they very often develop a true panic disorder as a result of their own behavior – they live in permanent anxiety of experiencing the next panic attack.

Generally speaking, the main trait of a panic attack disorder is the repetition of the panic attacks and of the occurrence of important changes in the person’s behavior.

People suffering from a panic attack disorder usually exhibit the following symptoms:
  • they have numerous panic attacks,
  • they permanently worry about their next panic attack that may occur at any time – without apparent reason or cause, and
  • they systematically avoid all the places where they once experienced a panic attack.
The impact of a panic attack can have a significant and lasting imprint and eventually lead to panic disorder symptoms, such as anticipatory anxiety and phobic avoidance.

Whilst anticipatory anxiety is provoked by the intense fear of having to experience future panic attacks, phobic avoidance makes you avoid certain places or situations where you previously experienced a panic attack and from where it could be difficult for you to escape or get some help.

People who suffer from panic attacks also very often avoid places where there is a chance of having a panic attack. Such places may include crowded areas, sportive or cultural events, buses, trains, airplanes, shops, etc.

In the worst case, phobic avoidance leads to agoraphobia or further mental problems.

Panic Disorder with Agoraphobia

People who suffer from panic disorder with agoraphobia deliberately avoid places where there is a chance of having a panic attack that could be witnessed by others, and where getting away may be difficult. Such places may include any kind of public place, crowded areas, etc.

People suffering from panic disorder with agoraphobia rarely leave their houses. In the worst case, phobic avoidance leads to agoraphobia or further mental problems.

Despite the fact that a panic disorder with agoraphobia can develop at any moment, it usually occurs within a year of the first recurrent panic attacks.

Symptoms of panic disorder with agoraphobia

A panic disorder with agoraphobia can show physical, psychological, and behavioral symptoms when the sufferer is in an environment or a situation susceptible to causing anxiety.

Typical physical symptoms of a panic disorder with agoraphobia

Physical symptoms of panic disorder with agoraphobia occur fairly rarely as the people suffering from this panic disorder do their utmost not to be placed in situations likely to trigger a panic attack. When symptoms of panic disorder with agoraphobia occur, people may among others experience some or a combination of the following symptoms:
  • Breaking out in a sweat,
  • chest pain,
  • diarrhea,
  • dizziness,
  • feeling hot,
  • flushing,
  • feeling light-headed,
  • nausea,
  • pounding heart,
  • rapid and shallow breathing,
  • ringing in the ears,
  • sensation of choking or smothering,
  • shaking,
  • stomach ache,
  • tingling or numbness in the fingers and toes,
  • trembling,
  • trouble swallowing, etc.
Typical psychological symptoms of panic disorder with agoraphobia

Psychological symptoms of panic disorder with agoraphobia occur more often and are sometimes associated with the physical symptoms of panic disorder. When symptoms of panic disorder with agoraphobia occur, people usually experience the following symptoms:

They develop an intense fear that
    - the people surrounding them may notice their panic attack and their embarrassment,
    - that their heart stops working during the panic attack, and that they may die,
    - they might faint or go crazy.

Further possible physical symptoms of panic disorder with agoraphobia

The occurrence of the following psychological symptoms of panic disorder with agoraphobia is also possible:

The people who suffer from panic disorder with agoraphobia are characterized by low self-confidence and self-esteem, suffer from depression and loss of control, are convinced that they are dependent on a “trusted helper” to survive and therefore constantly fear being ‘left alone.’

Typical behavioral symptoms of panic disorder with agoraphobia

Behavioral symptoms of panic disorder with agoraphobia occur fairly regularly and are usually divided into 4 distinct behavioral groups:
  • avoidance,
  • reassurance,
  • safety and
  • escape.
“Avoidance” – A behavioral symptom of panic disorder with agoraphobia

People suffering from this type of panic disorder with agoraphobia maximize their efforts to avoid all imaginable situations, places, and environments that could trigger any kind of anxiety. Their main concern is to avoid all kinds of public places, crowded areas, trains, ships, airplanes, etc., and to be ‘trapped’ somewhere.

For some people, this panic disorder with agoraphobia can become so severe that they find any excuse not to have to leave their house – the only place where they can feel safe.

“Reassurance” – A behavioral symptom of panic disorder with agoraphobia

People suffering from panic disorder with agoraphobia constantly need to be in the company of a so-called ‘trusted person’ whose duty is to reassure them at any moment. Visiting an old good friend or going shopping around the corner are actions that a person suffering from this kind of panic disorder would not consider if he or she was not sure that his or her ‘trusted person’ will be at his side all the time.

The level of an untreated panic disorder with agoraphobia can become so high and the symptoms so intense that the sufferer is no longer capable of staying alone in his own house or flat.

“Safety” – A behavioral symptom of panic disorder with agoraphobia

People suffering from panic disorder with agoraphobia constantly feel the need to follow or stick to a certain ritual before leaving their house to ‘enter’ any kind of public place, crowded areas, trains, etc. Some may feel the absolute necessity of having a ritual drink in order to feel safe. Others may check and recheck a few times that they have not forgotten to put their medicine or tablets in their pocket before leaving their house. Without this ‘safety procedure, these people would not put a foot outside.

“Escape” – A behavioral symptom of panic disorder with agoraphobia

People suffering from this type of panic disorder with agoraphobia know only one solution and reaction when they are confronted with situations, places, or environments that could possibly trigger their anxiety. They suddenly feel a strong need to escape the stressful place on the spot and return home as quickly as possible.

Usual side effects of panic attacks

When a person experiences one or two panic attacks in his or her lifetime, he or she has no reason to worry. The situation is however quite different when the person’s panic attack symptoms occur more frequently and lead to a true anxiety disorder. The person is then said to suffer from panic attack disorder (also called panic disorder).

Panic attack disorder has shown that it can also predispose people suffering from the disorder to develop gradually heart disease.

Both anxiety disorder and panic disorder are serious medical conditions that can influence very negatively a person’s quality of life if the condition itself is not treated adequately.

A panic attack can generate many side effects, but the most feared one is triggered by the own reactions of the panic attack sufferer, i.e., by his or her intense fear or worry of experiencing a further incident of the kind in the future.

Economic issues can also be another side effect of an untreated or not satisfactorily treated panic attack: people are no longer capable of keeping their job; if they are lucky enough to find a new one, it will definitely be a low-paid one where they earn much less.

Causes of panic attacks and panic disorder

Although the exact cause of panic attacks and panic attack disorder is not yet completely understood, factors, such as genetics, brain abnormalities, substance abuse, and major life stress are believed to also be involved.

Panic attack disorder imputable to genetics (family history)

A panic attack disorder has been observed to run in a lot of families so inheritance could play here a major role and would pass the panic attack disorder from one generation to the next one. There are however also a lot of people who do not have a family history of panic attack disorder, but who suffer anyhow of a panic disorder.

Panic attack disorder imputable to brain abnormalities

Functional problems in parts of the human brain are said to be responsible for the occurrence of panic attack disorder.

Panic attack disorder imputable to substance abuse

Certain substances, such as alcohol, caffeine, and illicit drugs have often been reported to worsen a panic attack disorder.

Panic attack disorder imputable to major life stress

Stressful events, such as the death of a spouse, husband, child, or a close family member, a divorce, detention in jail, being fired from work, experiencing a major change in health or behavior of a family member, a major personal injury or illness, etc. can trigger a panic attack disorder.

Possible triggers for a panic attack

While psychologists classify panic attacks under unexpected types, situationally bound types, and situationally disposed types, scientists cannot yet explain why a certain situation or event will generate a panic attack in one person and not in another one.

Unexpected panic attacks: Unexpected panic attacks usually occur spontaneously and out of the blue, even while a person is relaxing in front of the TV or reading a technical magazine, or sleeping calmly in his own bed. The actual reason has not been found yet, but the majority of scientists believe that panic attacks are biologically triggered.

Situationally bound panic attacks: Situationally bound panic attacks are repeatedly triggered by a specific situation, like walking or driving through a tunnel, crossing a bridge, or by an event, like a crowded area, a sportive, or a cultural event. A situationally bound panic attack is usually triggered when the suffering person faces the specific situation or simply anticipates having to face it.

When the sufferer consistently avoids facing the feared panic attack triggering situations or events, their number usually increases over time. In other words, when a person experiences his or her first panic attack driving through a tunnel, the next one may occur when riding on the highway or flying.

Situationally predisposed panic attacks: Situationally predisposed panic attacks are very similar to situationally bound panic attacks. A situationally predisposed panic attack is also triggered by a specific situation but the attacks only occur from time to time and not always immediately when the suffering person faces the specific situation.

In other words, when a person experiences his or her first panic attack driving through a tunnel, the next few times can take place without triggering a panic attack, and the next panic attack can occur in the middle of the tunnel.

Triggers are also generated by a combination of physical and psychological causes of panic disorder.

Although the first attack usually occurs without any apparent reason, the person suffering from panic attacks may personally be mainly responsible for the triggering of the next ones caused by his behavior, i.e. his reactions to the physical symptoms of a panic attack that mostly lead to situationally bound panic attacks and to situationally predisposed panic attacks.

In other words, if a person suffering from panic disorder experiences a “pounding heart” after consuming some alcohol, coffee, or a new medication, he or she may falsely interpret the situation as “clear panic attack symptoms” and eventually his or her own anxiety triggers the actual panic attack.

Alcohol, coffee, or a new medication can also be responsible for the emergence of an actual panic attack. The big problem with sufferers of panic attacks is that they do not have any possibility of isolating the various triggers connected with a panic attack.

Further major stressful events, such as the death of a spouse, husband, child, or a close family member, a divorce, detention in jail, being fired from work, experiencing a major change in health or behavior of a family member, a major personal injury or illness, etc. can trigger a panic attack disorder.

Risk factors associated with panic attack disorder

Panic attack disorder affects approximately three percent of American adults, whereby women are more likely to experience a panic attack disorder than men. The following factors are believed to increase a person’s risk of experiencing a panic attack disorder:

Your age may be a risk factor for a panic attack disorder

Panic attack disorder generally builds up before age 25 while environmental and personal injury-related panic attack disorder already develops from age 5 on. Situational panic attack disorder already starts developing around age 15-18.

Your sex may be a risk factor for a panic attack disorder

Both sexes can be affected by panic attack disorder. However women appear to be more affected than men; they see more often a doctor, get diagnosed and the disorder is treated. Most men are generally less willing to seek help; some categorically refuse to consult a doctor for emotional matters.

Your own family may be a further risk factor for a panic attack disorder

When a person lives in a family with fears and a phobias history, he or she is more likely to experience a panic attack disorder, too.

Any traumatic event may also be a risk factor for a panic attack disorder

When a person experiences a traumatic event, like being trapped in a lift, indecently assaulted in a garage, or attacked by a dog – such events may be the starting point for the development of a severe panic attack disorder.

Complications of untreated panic attacks

When a panic attack or panic attack disorder does not receive genuine treatment, the sufferer is likely to experience repeated panic attacks for months or years. The symptoms of these continued panic attacks can easily develop into other mental illnesses, such as phobias, agoraphobia, etc., and ruin his or her quality of life.

Panic attack disorder is also said to predispose the people who suffer from it to develop heart disease.

A panic attack or panic attack disorder may appear to be the cause of many complications, such as depression, financial problems, abuse of alcohol or substance, avoidance of critical situations, places, and environment, increased risk of suicide or suicidal thoughts, etc.

Note: An untreated panic attack or panic attack disorder may ‘improve’ at times but will not disappear unless the sufferer receives appropriate treatment for his or her panic attack disorder.

Are panic attacks serious? 

Yes. Panic attacks are truly real and awfully frightening for the persons who experience them. A panic attack strikes severe physical and emotional reactions out of the blue – although there is no actual danger.

The symptoms of a panic attack are very similar to those of a heart attack or some other life-threatening illnesses and may therefore be easily mistaken: the heart pounds and breathing is almost impossible. Approximately one in four people examined for chest pain by an emergency doctor is actually suffering from a panic attack.

People exhibiting ‘panic attack’ symptoms often have to pass several medical tests in order to make sure that they do not suffer from some other life-threatening illnesses. Very often the people who experience these symptoms are not correctly diagnosed and do not  receive the appropriate treatment for their panic attacks.

Generally, people living with or caring for a panic attack sufferer do their very best to assure and reassure the person that his or her life is not endangered by the panic attacks. Although absolutely correct, these remarks may make the panic attack sufferer understand that ‘everything is normal’, that he or she has to live with the problem, and that treatment is neither necessary nor possible at that moment.

A more positive approach to helping a person suffering from panic attacks consists in acknowledging objectively both his or her fear and the severity of the panic attack symptoms but in also re-emphasizing the non-life-threatening aspect of a panic attack. Any panic attack sufferer must be aware that his or her panic attack symptoms can also be treated successfully.

Are panic attacks dangerous?

Panic attacks can also be dangerous if they make you faint and you hit or hurt yourself severely. The degree of danger of a panic attack is comparable to what you may experience if you trip on a stone and fall.

However, when a panic attack imitates and masks a severe physical condition, like an undiagnosed heart disease, and the person who experiences the panic attacks is aware that his or her symptoms are very similar to those of a heart attack, that person will most probably not seek help immediately and may find himself or herself in a very dangerous situation.

Panic attack disorder – When to see a doctor?

If you ever experience any panic attack symptoms, do not hesitate a second and seek immediate medical help. If not correctly diagnosed and treated adequately by a professional, panic attacks may worsen. The main problem with a panic attack is that panic attack symptoms are very similar to those of a serious heart attack and that a wrong diagnosis may have significant consequences for the person.

Your appointment with a professional for panic attack disorder

Taking the decision to seek help for your fears and phobias and making an appointment with your primary care doctor is most probably the most important step you can make in this connection to improve your condition. Should you happen to have intense fears related to your panic attack, you will surely be transferred to a specialized mental health provider for further consideration and appropriate treatment.

It is always a good idea to get prepared for your appointment and to bring along with you your “Panic Attack Diary” in which you have written down – as detailed as possible – when and under which circumstances both physical and psychological symptoms have occurred, how you have tried to deal with them, and what results you have obtained.

It is also recommended to make a checklist of all of your key personal information, possible stresses, and important recent changes in your life and to describe shortly how badly and when they have affected you.

To complete the picture, you can work out a list of all your medications, inclusive dosages, and directions and ask a trusted family member or friend to accompany you to your appointment, and help you remember all information received.

Tests and diagnosis

Your primary care doctor or other health care provider will make you pass different exams and tests to find out if your symptoms result from a panic attack, a panic disorder, or another serious condition. The symptoms exhibited by a heart attack or thyroid problems are very similar to those of a panic attack.

Criteria to be diagnosed with panic disorder

When a person experiences panic attacks, he or she does not necessarily suffer from a panic disorder. In accordance with the criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association, the following criteria have to be met for a person to be diagnosed with panic attack disorder:
  1. The panic attacks must be both frequent and unexpected.
  2. At least one of the panic attacks must have been followed by a minimum of one month of constant worry about experiencing another attack; continuous fear of the terrific consequences of a panic attack, such as fainting, losing control, experiencing a heart attack, or "going crazy" or significantly changing the person’s behavior, e.g. avoiding situations that he or she believes could cause a panic attack.
  3. The experienced panic attacks have not been triggered by alcohol or substance abuse, a social phobia, or an obsessive-compulsive disorder.
More rarely, panic disorder with agoraphobia is diagnosed for some people whose main worry consist in avoiding situations, places, or environment that may result in triggering a new panic attack, or from places where they fear experiencing a panic attack that could be witnessed by others, and from where getting away – or getting help – might be difficult.

People suffering from panic attacks but not from a so-called diagnosed panic disorder can also benefit from genuine treatment. One should always keep in mind that an untreated panic attack can worsen and might also easily develop into severe panic disorder or phobias.

Why does it take so long to diagnose panic attacks?

The great similarity between panic attack symptoms and those of a heart attack or some other life-threatening illnesses is, for sure, the main reason why it takes so long – for the majority of people suffering from panic attacks – to be properly diagnosed with panic attack. Very often doctors do perform extensive medical check-ups to systematically rule out the most dangerous conditions until the patient’s panic attack is finally diagnosed.

The consequence of such long-lasting check-ups is that the person who suffers from an undiagnosed and consequently not medically treated panic attack is at particular risk of developing depression. In fact, up to thirty percent of the people who suffer from panic attack disorder are said to develop with times a serious major depression

Treatments for panic attack and panic disorder

Research has made it possible for sufferers of panic attack to have several treatment options available for controlling and removing their panic attack symptoms. Psychotherapy and medications are both appropriate options to treat effectively panic attack symptoms.

Depending on the history, the severity and intensity of the person’s panic disorder, and the availability of specially trained therapists, the doctor or other health care provider will suggest applying the psychotherapy treatment, the medication treatment, or possibly both of them.

Psychotherapy for panic attacks and panic disorder

Psychotherapy – sometimes called “therapy” for short – actually uses quite a number of treatment techniques and is often referred to as a first-choice treatment to effectively treat panic attacks and panic attack disorder.

Through psychotherapy, people learn to better understand and identify their personal life problems and events that have led to their panic attacks and panic attack disorder. Psychotherapy also helps them regain a sense of control and learn to effectively cope with their panic attach and panic attack disorder.

Cognitive behavioral therapy (CBT) is said to be the most commonly applied one; its objective is to make people learn – using their own experience – that panic attack symptoms are not dangerous despite the overwhelming fear, nervousness, and anxiety that they cause.

The procedure applied during the sessions is as follows: the therapist will usually assist his patient – in a safe environment – recreating and reviving the typical symptoms of a panic attack. From the moment the sensations of panic attacks stop being perceived as threatening, the therapy start showing the first positive effects and the patient’s panic attacks start getting resolved.

The successful treatment of a particular panic attack is likely to make the person overcome more easily the overwhelming fears of objects or situations he or she used to avoid because of the ‘expected’ panic attacks.

The therapy sessions will usually start on a weekly basis. The first signs of improvement in the panic attack symptoms are usually noticed after a few weeks. The intensity of the panic attack symptoms often decreases gradually or disappears within a few months.

With the panic attack symptoms improving gradually, the patient may work out – together with his or her therapist – a plan to reduce gradually the number of sessions.  Further occasional meetings should also be fixed to make sure that the panic attack does not worsen over time and remain under control.

Medication for panic attacks and panic disorder

Medication can also be an option to help control or reduce temporarily the intensity of a few symptoms of panic disorder. Medication cannot resolve panic attack symptoms. Medication treatment can however be recommended in severe cases and be effective when it is used in combination with a therapy treatment and lifestyle changes.

Medications that have shown to be effective in ‘managing’ panic attack symptoms:

Selective serotonin reuptake inhibitors (SSRIs): These are antidepressants that are recommended as the first choice to treat panic attacks. They are FDA approved for the treatment of panic disorder.

Serotonin and norepinephrine reuptake inhibitors (SNRIs): These are another class of antidepressants that are also recommended to treat panic attacks. They are FDA approved for the treatment of panic disorder.

Benzodiazepines: Benzodiazepines are mild sedatives. They are FDA approved for the treatment of panic disorder.

Self-help recommendations for panic attacks and panic disorder

The following recommendations can help you better control your panic attacks, and panic attack disorder:
  • Get a maximum of information and learn as much as you can about anxiety, panic attack, panic attack disorder, and their symptoms.
  • Avoid smoking and consuming caffeine and taking stimulants as they can trigger panic attacks in some people.
  • Learn the techniques to control your breathing so that you know how to react and calm down when your panic attack starts.
  • Do some relaxation techniques, such as yoga or meditation to help you better respond to your panic attack.

Prevention for Panic Attack and Panic Disorder

“Can panic attacks and panic attack disorder be prevented?” There is of course no sure way yet to prevent a panic attack to occur. However, everybody can take self-care steps in order to better control their stress and enhance their resilience.

It is also important to be aware of the fact that having had an episode of a panic attack and suffered from the related threatening symptoms automatically puts you at high risk of experiencing a new one.

The best method to ‘control’ the occurrence of the next episode of a panic attack is to learn about them and be aware of their triggers or possible causes, to absolutely stick to the treatment schedule arranged together with your primary care doctor, alternative practitioner, or therapist, and to carry on taking the prescribed medications.

Additionally, doing regular physical activities is a plus to help you avoid relapse.

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