Panic disorder is a mental health issue that affects at least 5% of the population at some point in life (Roy-Byrne, Craske, & Stein, 2006; Torpy, Burke, & Golub, 2011). Panic attacks and related complaints are a widespread concern in the medical community with increasing numbers of individuals seen in emergency rooms each year (Kao et al., 2014), there is a need for increased research to the variety of ways in which panic attacks manifest in sufferers, and how to best treat them.
Broad Range of Symptoms Cause Confusion
One of the reasons for the different diagnoses and concerns among medical as well as mental health professionals regarding the different types of panic attacks and disorders is that the symptoms themselves range broadly (Kircanski, Craske, Epstein, & Wittchen, 2009). The common symptoms most associated with a panic attack are fear, or even stark terror, and feelings of anxiousness. These are what are considered cognitive symptoms, and are often only known to the individual. Standard physiological symptoms include racing heart, increased respirations, perspiring, reddening of the face or blotchiness of the skin. In extreme cases of panic attack, there could be nausea, vomiting, or even diarrhea involved (Roy-Byrne, Craske, & Stein, 2006).
The DSM-5 criteria for panic disorder include recurrent panic attacks within 30 days, with concerns about having another and suffering the consequences of having a panic attack. Panic disorder belongs to a family of anxiety-related mental health illnesses. Others include agoraphobia, anxiety disorder, generalized anxiety, obsessive-compulsive disorder, social anxiety, phobias (Torpy et al., 2011) and even hoarding disorder (Raines, Oglesby, Short, Albanese, & Schmidt, 2014). This list is not exhaustive, and this is one of the reasons for the difficulty in pinpointing origins.
Studies over the past years have focused much attention on co-morbidity factors about panic attacks. Common to many sufferers of panic attacks is substance abuse (Potter et al., 2014). It is not uncommon for persons with mental illness to self-medicate. Therefore, an individual with severe anxiety or panic attacks might use marijuana or alcohol to ease anxiety or delay an attack. This route is dangerous to pursue due to the risk of dependence on substances, which serves only to increase physiological as well as cognitive symptomology as these are very closely related to withdrawal symptoms (Roy-Byrne, Craske, & Stein, 2006).
Other co-morbidity factors include two or more anxiety-related disorders, such as social anxiety disorder, agoraphobia, and depression (Brown et al., 2016). The symptomology amongst these are so similar it makes diagnosis and treatment difficult (Torpy et al., 2011). One of the key factors in determining if a panic attack may be due to panic disorder is if there has been a past major depressive episode. Researchers have also found that most individuals with panic disorder have had two major onsets, one during adolescence and one during the late thirties, again, with women represented more often than men (Katon, 2006).
There is no empirical data to support facts as to why the onsets occur during these two times, it could be inferred that the onset is due to the anxiety related to being a teen with adulthood in front (Hayward, Killen, Kraemer, & Taylor 2000), and of being an adult in the late 30s with so much still left to accomplish, such as established professionally, owning a home, and having children.
Theorizing the Unknown
Roy-Bryne, Cask, and Stein (2006) describe what is known about panic attacks as, "imprecise, though increased understanding" of treatments. The authors further suggest getting the most current and relevant research to the front lines of the medical and mental health industry is vital due to the increasing incidences of panic attacks. Currently, the number of studies and topics are broadly diverse.
One group of researchers (Asnaani, Gutner, Hinton, & Hofmann, 2009) have looked at race and ethnicity as predictors of panic disorder. They found that White individuals are more prone to panic attacks than their Black, Asian, or Hispanic counterparts. The authors indicated this might be due to White culture, which has had a fear instilled of dying of illness in general but specifically dying of a heart attack. The conclusions they drew for any discrepancies in their research, i.e., Asians not being more high-strung and anxiety prone was based upon assimilation factors, i.e., becoming more Americanized.
More salient theories include genetic factors, stressful life, past depression, or a traumatic event. Even with this narrow of a field, several studies dissect these into smaller subsets of one another. For example, Zvolensky, Feldner, Leen-Feldner, and McLeish, (2005) examined the correlation between cigarette smoking and panic attacks. They found that a higher number of people smoke due to anxiety. As nicotine affects the central nervous system, acts as a stimulant, use of nicotine could account for increased heart rate and respiratory issues.
There are some studies that suggest that anxiety could be seasonal, related to holidays (Kao et al., 2014), or relative to a day or days of the week. Kao et al. (2014) found there is an increase in emergency room cases about anxiety and panic attacks. There has been much study into seasonal affective disorder (Kurlansik & Ibay, 2012) a type of seasonal depression that generally occurs during the winter months when individuals do not get as much exposure to sunshine or are not as social. Seasonal anxiety could be related to that, due to the fear of becoming depressed.
Carleton, Fetzner, Hackl, and McEvoy (2013) posit that some individuals suffer from panic attacks due to the discomfort uncertainty of the unknown, while others propose that individuals become panicked over anticipated events or even the panic or depression themselves (Helbig-Lang, Lang, Petermann, & Hoyer, 2012). It can be reasoned that both of these are related to past experiences, or at least a history of imagining some catastrophic event.
The imagining of a socially catastrophic event is believed to be an important underlying factor of social anxiety disorder (Brown et al., 2016). Some think that social anxiety is co-morbidity for panic disorder (Potter et al., 2014); others feel it should be considered a spectrum disorder for panic disorder (Zvolensky, Feldner, Leen-Feldner, & McLeish, 2005). Many panic attacks are related to either the uncertainty of social events or the fear of having a panic attack while in a social or a public setting (Brown et al., 2016).
The Fear of Everything Factor
Zvolensky et. al.'s (2005) research discusses the prevalence of situational panic attacks about panic disorders, social anxiety, and agoraphobia, indicating that situational panic attacks are added to diagnostic criteria with some psychiatric disorders in the DSM-5. Situational anxiety or panic attacks occur when individuals become hyper anxious over certain events, places, or even people.
For example, if a person has been reprimanded at work, he or she may become avoidant about going to work for fear of further reprimand, even when there is no indication that there is one forthcoming (Carleton et al., 2014). It does seem counterintuitive for this individual to avoid work, perhaps arriving late, or even missing days. However, when someone suffers from an anxiety related disorder, they lose the ability to think in these terms for their objective is about protecting themselves from discomfort.
There is a preponderance of research in support of the thinking that persons affected with generalized anxiety disorders are more susceptible to panic attacks, or panic disorders (Van Ameringen, Simpson, Patterson, & Mancini, 2013). When a person is diagnosed with generalized anxiety disorder, it is because he or she exhibits both cognitive and physiological symptoms of anxiety over an extended period, yet they do not seem to be specific triggers for the anxiety (Tull, Stipelman, Salters-Pedneault, & Gratz, 2009). This description is reminiscent of the Charlie Brown episode when Lucy provided a diagnosis that included the "fear of everything."
The reference to Charlie Brown is certainly not intended to make light of the situation. Charlie Brown was intended as an allegory for the social and political times in which the cartoon was created post-Korean War and during the Viet Nam War. There was so much uncertainty during those times; the world was changing, in the midst of war abroad, there was war in the streets of the United States as persons of color fought for their civil rights. Charlie Brown, being a young, suburban middle-class White male had cause to by hyper-anxious. In fact, he would certainly fit the model for Carleton, Fetzner, Hackl, & McEvoy (2013) studies on panic attacks and the intolerance of uncertainty.
Nothing to Fear, but Fear Itself
There has been an increase in panic attack-related emergency room visits in recent years; many feel this may be related still to the 911 attacks (Van Ameringen, Simpson, Patterson, & Mancini, 2013) when suddenly the entire world seemed to be living on the edge of uncertainty. Due to the variety of symptomology that patients present in these visits, doctors have realized that case studies may be the most reliable means of collecting empirical data on panic attacks (Katon, 2006).
While controlled experiment studies are necessary and have furthered research, many of the results appear to be unreliable. For example, in a recent study (Meuret et al., 2011) participants, male and female, knew they were being observed and that they were attached to machines to monitor heart and breathing rates. The purpose of this study was to measure the occurrence of spontaneous panic attacks without triggers. What the study found was that there were patterns of instability detected several minutes before the onset of the attack, and the actual onset was signalled by increased heart-rate. It is reasonable to infer that subjects, who signed informed consents and were attached to heart and respiratory monitors, experienced panic attacks because it was expected, or anticipated (Helbig-Lang, Lang, Petermann, & Hoyer, 2012).
Some researchers also suggest that panic attacks can be brought on by the fear of death or disease, this was a contributing factor in the ethnic study where the authors posited that White Americans were more likely to be fearful of health concerns (Asnaani, Gutner, Hinton, & Hofmann, 2009). The idea that health concerns are primarily a White American trait is not something most would lend much credence. However, it is reasonable to assume that anyone experiencing a panic attack with racing heart and chest pains, might experience fear over having a heart attack (Carleton et al., 2014), which would, in turn, increase feelings of panic.
Where the Heart is Involved: Get A Second Opinion
In another study, researchers have found that there are incidents of non-fear and non-cardiac related incidents of panic attacks (Foldes-Busque et al., 2015). In these cases, an individual shows up in the emergency room or doctor's office presenting with chest pains, assumes it is cardiac related, but tests do not support this. When told they are having a panic attack, because they have not felt the cognitive symptoms of fear, feelings of losing control or going crazy, the individuals discount it. In survey results, Foldes-Busque et al. (2015) found that these individuals were less likely to follow up with a mental health practitioner.
In a case involving a 48-year-old woman who presented with symptoms of a panic attack with both cognitive and physical symptomology, i.e., fear, racing heart, chest pain, increased breathing, because she was a middle-aged White woman, the emergency room doctors immediately diagnosed her with a panic attack. However, upon review of her medical history, she had never been diagnosed with depression, aside from mild post-partum 12 years earlier, had never had a panic attack, and could think of nothing occurring in her life that might contribute to a panic attack.
Had she not been wearing a cast for a broken ankle, the doctors might have sent her away with a prescription for benzodiazepines and called it a day. However, the physician (Schlicht et al., 2014) who documented her case as a teaching moment, found that she, in fact, was presenting with these symptoms due to decreased circulation, which caused symptoms of hypertension related to ventricular thrombosis that had formed in the leg with the cast. Had she been sent home, she may have had a heart attack or stroke at some later point.
Research Everywhere, Still Know not What to Think
There seems to be no end to research on panic attacks and panic disorders. Most suggest findings that seem common sense. For example, one study found that agoraphobics may experience anxiety due to a lack of assertiveness (Levitan, Simoes, Sardinha, & Nardi, 2016). However, research is necessary, and especially research involving case studies with individuals who document their organic experiences with panic attacks (Katon, 2006). For these individuals, the fear of having to confront someone, or the fear of taking a vacant bus seat because someone else might want it, might mean their panic is their reaction to their lack of assertiveness. This information is something a therapist would need to know to work best with a client.
Conclusion and Recommendations
Having a greater understanding of the various forms and reasons people have panic attacks is beneficial. Some researchers believe that anxiety and panic are due to a form of unintended classical conditioning, which in turn causes the individual to overgeneralize. As a result, experiences panic attacks in response to unrelated stimuli or events. For example, a person could develop a conditioned fear of authority figures due to having grown up with a stern father (Lissek et al., 2010). Having a greater understanding has led to a recognition of the need for expanded research of subtypes of panic disorder (Kircanski, Craske, Epstein, & Wittchen, 2009). If uncertainty, fear of the unknown, and fear of having a panic attack contribute to and worsen panic attacks, then surely more knowledge can provide some measure of comfort to sufferers.
A greater understanding of panic attacks can lead to a greater understanding of how to treat panic attacks. The most successful treatment modalities include a combination of cognitive and behavioral therapies. Cognitive therapy helps the individual to explore thought patterns and identify triggers so that he or she can self-regulate. For example, if it is true that the anticipation of a panic attack increases the occurrence and mediates severity, panic attack sufferers can use this to their advantage.
With behavioral therapy, clients learn how to change behaviors that are employed to protect or to avoid the stressor. These are usually negative behaviors. Like the individual who due to fear of reprimand takes sick days, or reports to work late. These actions are counter-intuitive and counter-productive. Through a combination of cognitive and behavioral modalities, this client can learn to change thought patterns and behavioral reactions to them. The individual in this illustration also lacked assertiveness, which as suggested by Levitan, Simoes, Sardinha and Nardi (2016), could lead to staying within the comfort zone to avoid confrontation - or having to defend one's actions. If a person has ample sick time and uses it, there is sufficient evidence to suggest this individual has agoraphobia.
There are steps a person who feels a panic attack coming on can take to reduce anxiety levels and allay the attack altogether. Breathing regulation is one of those means (Birch, 2015), and there is a fair amount of research to suggest that by performing cognitive appraisals, self-assessment of thought processes, this will lessen response to triggers. If an individual can recognize triggers, and what is going on with him or herself cognitively, then the individual can employ breathing exercises (Helbig-Lang, Lang, Petermann, & Hoyer, 2012).
For the individual experiencing a panic attack or who lives in dread of having the next one, life is uncomfortable, and the dread can even prove debilitating. It is important to recognize that to the person who does not suffer from an anxiety-related disorder, or who is not in the midst of a stressful situation that has resulted in a panic attack, much of what is addressed in this article seems so simple. It could be that through having an awareness of the simplicity, the person with anxiety feels even more due to feelings of helplessness.
If an individual has a condition that interferes with his or her ability to function, it is a disorder. If this condition is related to mental functioning and emotions, it is classified as a mental disorder. Seeking therapy for panic attacks or panic disorder is as routine as seeking care from an ear, nose, and throat specialist for a stubborn cold. It is important to see someone who has the education and background necessary to help.
For the individual who suffers from panic attacks, the act of seeking help may be difficult. Family members and friends can help. Cognitive-behavioral therapy received either face-to-face or from an online therapist can help individuals who suffer from panic attacks to retrain their thinking and behaviors. Springing from the midst of the preponderance of research on anxiety related disorders, researchers with an understanding of the importance of getting therapy, but also understanding the barriers to committing to it, conducted comparison studies with clients who received face-to-face therapy in weekly sessions with those who participated in online modules then "met" via email with their therapists once per week to discuss progress. The study showed that the benefits of online therapy were overall equal to that of face-to-face for clients with anxiety related disorders(Carlbring et al., 2005).
The benefits of online therapy for treatment for anxiety related disorders are the same as for other clients seeking mental health therapy, as a panic attack is a common feature of many mental health disorders.
Online mental health treatment is:
No matter what medium of treatment is selected, it is important for those who suffer from panic attacks to seek help from a qualified licensed professional. Panic attacks rob individuals of time, experience, and energy. Therapy can help individuals who experience panic attacks to regain control of their lives and improve their standard of living.