Anxiety and Related Disorders: Learn It 3—Panic Disorder

Panic Disorder

Imagine you’re our with friends and—suddenly, with no obvious trigger—you begin sweating and trembling. Your heart pounds, your breathing feels shallow, and you feel dizzy and nauseous. For several minutes, it can feel like something catastrophic is happening (like dying or “going crazy”). This kind of episode is called a panic attack.

A diagram shows an outline of a person’s upper body and internal organs including the brain, the lungs, the stomach, and the heart. The diagram shows the symptoms of a panic attack and the areas of the body these symptoms may express themselves. The brain is labeled, “Feeling dizzy, unsteady, lightheaded.” The heart is labeled, “Chest pain, palpitations and/or accelerated heart rate.” The lungs are labeled, “Shortness of breath.” The stomach is labeled, “Nausea or abdominal distress.”
Figure 1. Some of the physical manifestations of a panic attack are shown. People may also experience sweating, trembling, feelings of faintness, or a fear of losing control, among other symptoms.

panic disorder and panic attacks

Panic disorder involves:

  • recurrent, unexpected panic attacks, and

  • at least 1 month of persistent concern about having more attacks, worry about their consequences, and/or behavior changes meant to avoid attacks (e.g., avoiding exercise, unfamiliar places). 

A panic attack is an abrupt surge of intense fear or discomfort that peaks within minutes and includes physical and cognitive symptoms such as racing heart, sweating, trembling, shortness of breath, chest discomfort, dizziness, chills/hot flashes, nausea, and fears of losing control or dying.

Because panic attacks can mimic medical emergencies (especially heart-related symptoms), they sometimes lead to urgent care or ER visits—particularly the first time they happen.

How common is panic disorder?

Panic attacks themselves are not mental disorders. Indeed, around 23% of Americans experience isolated panic attacks in their lives without meeting the criteria for panic disorder (Kessler et al., 2006), indicating that panic attacks are fairly common.

According to the most recent nationally representative diagnostic survey (NCS-R, 2001-2003), approximately 2.7% of U.S. adults experience panic disorder in any given year, with a lifetime prevalence of 4.7%

Many people with panic disorder also experience agoraphobia (avoidance of situations where escape/help might be difficult if panic symptoms occur), and panic disorder often co-occurs with other anxiety disorders or major depressive disorder. 

Causes of Panic Disorder

Genetic Causes

Researchers are not entirely sure what causes panic disorder. Children are at a higher risk of developing panic disorder if their parents have the disorder (Biederman et al., 2001), and family and twins studies indicate that the heritability of panic disorder is around 43% (Hettema, Neale, & Kendler, 2001). The exact genes and gene functions involved in this disorder, however, are not well-understood.

Biological Causes

Neurobiological theories of panic disorder suggest that a region of the brain called the locus coeruleus may play a role in this disorder. Located in the brainstem, the locus coeruleus is the brain’s major source of norepinephrine, a neurotransmitter that triggers the body’s fight-or-flight response. Activation of the locus coeruleus is associated with anxiety and fear, and research with nonhuman primates has shown that stimulating the locus coeruleus either electrically or through drugs produces panic-like symptoms (Charney et al., 1990). Such findings have led to the theory that panic disorder may be caused by abnormal norepinephrine activity in the locus coeruleus (Bremner, Krystal, Southwick, & Charney, 1996).

Conditioning

Conditioning theories of panic disorder propose that panic attacks are classical conditioning responses to subtle bodily sensations resembling those normally occurring when one is anxious or frightened (Bouton, Mineka, & Barlow, 2001).

For example, consider a child who has asthma. An acute asthma attack produces sensations, such as shortness of breath, coughing, and chest tightness, that typically elicit fear and anxiety. Later, when the child experiences subtle symptoms that resemble the frightening symptoms of earlier asthma attacks (such as shortness of breath after climbing stairs), he may become anxious, fearful, and then experience a panic attack. In this situation, the subtle symptoms would represent a conditioned stimulus, and the panic attack would be a conditioned response. The finding that panic disorder is nearly three times as frequent among people with asthma as it is among people without asthma (Weiser, 2007) supports the possibility that panic disorder has the potential to develop through classical conditioning.

Cognitive Factors

Cognitive models emphasize catastrophic misinterpretation of normal bodily sensations (e.g., “My heart is racing—this must be a heart attack”), which increases fear, intensifies symptoms, and can spiral into a full panic attack.