Panic attack

Last updated
Panic attack
Panic attack.jpg
A depiction of someone experiencing a panic attack, being reassured by another person.
Specialty Psychiatry
Symptoms Periods of intense fear, palpitations, sweating, shaking, shortness of breath, numbness [1] [2]
Complications Self-harm, suicide [2]
Usual onsetOver minutes [2]
DurationSeconds to hours [3]
Causes Panic disorder, social anxiety disorder, post-traumatic stress disorder, drug use, depression, medical problems [2] [4]
Risk factors Smoking, psychological stress [2]
Diagnostic method After other possible causes excluded [2]
Differential diagnosis Hyperthyroidism, hyperparathyroidism, heart disease, lung disease, drug use, dysautonomia [2]
Treatment Counselling, medications [5]
Medication Antidepressant
Prognosis Usually good [6]
Frequency3% (EU), 11% (US) [2]

Panic attacks are sudden periods of intense fear and discomfort that may include palpitations, sweating, chest pain or chest discomfort, shortness of breath, trembling, dizziness, numbness, confusion, or a feeling of impending doom or of losing control. [1] [2] [7] Typically, symptoms reach a peak within ten minutes of onset, and last for roughly 30 minutes, but the duration can vary from seconds to hours. [3] [8] Although they can be extremely frightening and distressing, panic attacks themselves are not physically dangerous. [6] [9]

Contents

The essential features of panic attacks remain unchanged, although the complicated DSM-IV terminology for describing different types of panic attacks (i.e., situationally bound/cued, situationally predisposed, and unexpected/uncued) is replaced with the terms unexpected and expected panic attacks. Panic attacks function as a marker and prognostic factor for severity of diagnosis, course, and comorbidity across an array of disorders, including but not limited to anxiety disorders. Hence, panic attacks can be listed as a specifier that is applicable to all DSM-5 disorders. [10]

Panic attacks can occur due to several disorders including panic disorder, social anxiety disorder, post-traumatic stress disorder, substance use disorder, depression, and medical problems. [2] [4] They can either be triggered or occur unexpectedly. [2] Smoking, caffeine, and psychological stress increase the risk of having a panic attack. [2] Before diagnosis, conditions that produce similar symptoms should be ruled out, such as hyperthyroidism, hyperparathyroidism, heart disease, lung disease, drug use, and dysautonomia. [2] [11]

Treatment of panic attacks should be directed at the underlying cause. [6] In those with frequent attacks, counseling or medications may be used. [5] Breathing training and muscle relaxation techniques may also help. [12] Those affected are at a higher risk of suicide. [2]

In Europe, about 3% of the population has a panic attack in a given year while in the United States they affect about 11%. [2] They are more common in females than in males. [2] They often begin during puberty or early adulthood. [2] Children and older people are less commonly affected. [2]

Signs and symptoms

People with panic attacks often report a fear of dying or heart attack, flashing vision or other visual disturbances, faintness or nausea, numbness throughout the body, shortness of breath and hyperventilation, or loss of body control. [13] Some people also experience tunnel vision, mostly due to blood flow leaving the head to more critical parts of the body in defense. These feelings may provoke a strong urge to escape or flee the place where the attack began (a consequence of the "fight-or-flight response", in which the hormone causing this response is released in significant amounts). This response floods the body with hormones, particularly epinephrine (adrenaline), which aid it in defending against harm. [14]

A panic attack can result when up-regulation by the sympathetic nervous system (SNS) is not moderated by the parasympathetic nervous system (PNS). The most common symptoms include trembling, dyspnea (shortness of breath), heart palpitations, chest pain (or chest tightness), hot flashes, cold flashes, burning sensations (particularly in the facial or neck area), sweating, nausea, dizziness (or slight vertigo), light-headedness, heavy-headedness, hyperventilation, paresthesias (tingling sensations), sensations of choking or smothering, difficulty moving, depersonalization and/or derealization. [15] These physical symptoms are interpreted with alarm in people prone to panic attacks. This results in increased anxiety and forms a positive feedback loop. [16]

Shortness of breath and chest pain are the predominant symptoms. Many people experiencing a panic attack incorrectly attribute them to a heart attack and thus seek treatment in an emergency room. [17] Because chest pain and shortness of breath are hallmark symptoms of cardiovascular illnesses, including unstable angina and myocardial infarction (heart attack), a diagnosis of exclusion (ruling out other conditions) must be performed before diagnosing a panic attack. It is especially important to do this for people whose mental health and heart health statuses are unknown. This can be done using an electrocardiogram and mental health assessments.

Panic attacks are distinguished from other forms of anxiety by their intensity and their sudden, episodic nature. [14] They are often experienced in conjunction with anxiety disorders and other psychological conditions, although panic attacks are not generally indicative of a mental disorder.

Causes

There are long-term, biological, environmental, and social causes of panic attacks. In 1993, Fava et al. proposed a staging method of understanding the origins of disorders. The first stage in developing a disorder involves predisposing factors, such as genetics, personality, and a lack of well-being. [18] Panic disorder often occurs in early adulthood, although it may appear at any age. It occurs more frequently in women and more often in people with above-average intelligence. [19] [20] Various twin studies where one identical twin has an anxiety disorder have reported a high incidence of the other twin also having an anxiety disorder diagnosis. [21]

Biological causes may include obsessive-compulsive disorder, postural orthostatic tachycardia syndrome, post-traumatic stress disorder, hypoglycemia, hyperthyroidism, Wilson's disease, mitral valve prolapse, pheochromocytoma, and inner ear disturbances (labyrinthitis). Dysregulation of the norepinephrine system in the locus coeruleus, an area of the brain stem, has been linked to panic attacks. [22]

Panic attacks may also occur due to short-term stressors. Significant personal loss, including an emotional attachment to a romantic partner, life transitions, and significant life changes may all trigger a panic attack to occur. A person with an anxious temperament, excessive need for reassurance, hypochondriacal fears, [23] overcautious view of the world, [14] and cumulative stress have been correlated with panic attacks. In adolescents, social transitions may also be a cause. [24]

People will often experience panic attacks as a direct result of exposure to an object/situation that they have a phobia for. Panic attacks may also become situationally-bound when certain situations are associated with panic due to previously experiencing an attack in that particular situation. People may also have a cognitive or behavioral predisposition to having panic attacks in certain situations.

Some maintaining causes include avoidance of panic-provoking situations or environments, anxious/negative self-talk ("what-if" thinking), mistaken beliefs ("these symptoms are harmful and/or dangerous"), and withheld feelings.

Hyperventilation syndrome may occur when a person breathes from the chest, which can lead to over-breathing (exhaling excessive carbon dioxide related to the amount of oxygen in one's bloodstream). Hyperventilation syndrome can cause respiratory alkalosis and hypocapnia. This syndrome often involves prominent mouth breathing as well. This causes a cluster of symptoms, including rapid heartbeat, dizziness, and lightheadedness, which can trigger panic attacks. [25]

Panic attacks may also be caused by substances. Discontinuation or marked reduction in the dose of a substance such as a drug (drug withdrawal), for example, an antidepressant (antidepressant discontinuation syndrome), can cause a panic attack. According to the Harvard Mental Health Letter, "the most commonly reported side effects of smoking marijuana are anxiety and panic attacks. Studies report that about 20% to 30% of recreational users experience such problems after smoking marijuana." [26] Cigarette smoking is another substance that has been linked to panic attacks. [27]

A common denominator of current psychiatric approaches to panic disorder is that no real danger exists, and the person's anxiety is inappropriate. [28]

Panic disorder

People who have repeated, persistent attacks or feel severe anxiety about having another attack are said to have panic disorder. Panic disorder is strikingly different from other types of anxiety disorders in that panic attacks are often sudden and unprovoked. [29] However, panic attacks experienced by those with panic disorder may also be linked to or heightened by certain places or situations, making daily life difficult. [30]

Agoraphobia

Agoraphobia is an anxiety disorder that primarily consists of the fear of experiencing a difficult or embarrassing situation from which the affected cannot escape. Panic attacks are commonly linked to agoraphobia. [31] People with severe agoraphobia may become confined to their homes, experiencing difficulty traveling from this "safe place". [32] The word "agoraphobia" comes from the Greek words agora (αγορά) and Phobos (φόβος), the term "agora" referring to the city centre in an ancient Greek city. In Japan, people who exhibit extreme agoraphobia to the point of becoming unwilling or unable to leave their homes are referred to as Hikikomori . [33] The phenomena in general is known by the same name, and it is estimated that roughly half a million Japanese youths are Hikikomori. [34]

People who have had a panic attack in certain situations may develop phobias of these situations and begin to avoid them. Eventually, the pattern of avoidance and level of anxiety about another attack may reach the point where individuals with panic disorder are unable to drive or even step out of the house. At this stage, the person is said to have panic disorder with agoraphobia. [35]

Experimentally induced

Panic attack symptoms can be experimentally induced in the laboratory by various means. Among them, for research purposes, by administering a bolus injection of the neuropeptide cholecystokinin-tetrapeptide (CCK-4). [36] Various animal models of panic attacks have been experimentally studied. [37]

Neurotransmitter imbalances

Many neurotransmitters are affected when the body is under the increased stress and anxiety that accompany a panic attack. Some include serotonin, GABA (gamma-aminobutyric acid), dopamine, norepinephrine, and glutamate. More research into how these neurotransmitters interact with one another during a panic attack is needed to make any solid conclusions, however.

An increase of serotonin in certain pathways of the brain seems to be correlated with reduced anxiety. More evidence that suggests serotonin plays a role in anxiety is that people who take SSRIs tend to feel a reduction of anxiety when their brain has more serotonin available to use. [38]

The main inhibitory neurotransmitter in the central nervous system (CNS) is GABA. Most of the pathways that use GABA tend to reduce anxiety immediately. [38]

Dopamine's role in anxiety is not well understood. Some antipsychotic medications that affect dopamine production have been proven to treat anxiety. However, this may be attributed to dopamine's tendency to increase feelings of self-efficacy and confidence, which indirectly reduces anxiety. [38]

Many physical symptoms of anxiety, such as rapid heart rate and hand tremors, are regulated by norepinephrine. Drugs that counteract norepinephrine's effect may be effective in reducing the physical symptoms of a panic attack. [38] Nevertheless, some drugs that increase 'background' norepinephrine levels such as tricyclics and SNRIs are effective for the long-term treatment of panic attacks, possibly by blunting the norepinephrine spikes associated with panic attacks. [39]

Because glutamate is the primary excitatory neurotransmitter involved in the central nervous system (CNS), it can be found in almost every neural pathway in the body. Glutamate is likely involved in conditioning, which is the process by which certain fears are formed, and extinction, which is the elimination of those fears. [38]

Pathophysiology

The symptoms of a panic attack may cause the person to feel that their body is failing. The symptoms can be understood as follows. First, there is frequently the sudden onset of fear with little provoking stimulus. This leads to a release of adrenaline (epinephrine) which brings about the fight-or-flight response when the body prepares for strenuous physical activity. This leads to an increased heart rate (tachycardia), rapid breathing (hyperventilation) which may be perceived as shortness of breath (dyspnea), and sweating. Because strenuous activity rarely ensues, the hyperventilation leads to a drop in carbon dioxide levels in the lungs and then in the blood. This leads to shifts in blood pH (respiratory alkalosis or hypocapnia), causing compensatory metabolic acidosis activating chemosensing mechanisms that translate this pH shift into autonomic and respiratory responses. [40] [41]

Moreover, this hypocapnia and release of adrenaline during a panic attack cause vasoconstriction resulting in slightly less blood flow to the head which causes dizziness and lightheadedness. [42] [43] A panic attack can cause blood sugar to be drawn away from the brain and toward the major muscles. Neuroimaging suggests heightened activity in the amygdala, thalamus, hypothalamus, and brainstem regions including the periaqueductal gray, parabrachial nucleus, and Locus coeruleus. [44] In particular, the amygdala has been suggested to have a critical role. [45] The combination of increased activity in the amygdala (fear center) and brainstem along with decreased blood flow and blood sugar in the brain can lead to decreased activity in the prefrontal cortex (PFC) region of the brain. [46] There is evidence that having an anxiety disorder increases the risk of cardiovascular disease (CVD). [47] Those affected also have a reduction in heart rate variability. [47]

Cardiovascular disease

People who have been diagnosed with panic disorder have approximately double the risk of coronary heart disease. [48] Certain stress responses to depression also have been shown to increase the risk and those diagnosed with both depression and panic disorder are nearly three times more at risk. [48]

Diagnosis

According to the DSM-5 a panic attack is part of the diagnostic class of anxiety disorders. It is not considered a specific disorder on its own, with the symptoms of a panic attack regarded as characteristics of another disorder during which the panic attack occurs. [49] DSM-5 criteria for a panic attack is defined as "an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes and during which time four or more of the following symptoms occur": [49]

In DSM-5, culture-specific symptoms (e.g., tinnitus, neck soreness, headache, and uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms.

Some or all of these symptoms can be found in the presence of a pheochromocytoma.

Screening tools such as the Panic Disorder Severity Scale can be used to detect possible cases of disorder and suggest the need for a formal diagnostic assessment. [50] [51]

Treatment

Panic disorder is usually effectively treated with a variety of interventions, including psychological therapies and medication. [52] [14] Cognitive-behavioral therapy has the most complete and longest duration of effect, followed by specific selective serotonin reuptake inhibitors. [53] A 2009 review found positive results from therapy and medication and a much better result when the two were combined. [54]

Lifestyle changes

Caffeine may cause or exacerbate panic anxiety. Anxiety can temporarily increase during withdrawal from caffeine and various other drugs. [55]

Increased and regimented aerobic exercise such as running has been shown to have a positive effect on combating panic anxiety. There is evidence that suggests that this effect is correlated to the release of exercise-induced endorphins and the subsequent reduction of the stress hormone cortisol. [56]

There remains a chance of panic symptoms becoming triggered or being made worse due to increased respiration rate that occurs during aerobic exercise. This increased respiration rate can lead to hyperventilation and hyperventilation syndrome, which mimics symptoms of a heart attack, thus inducing a panic attack. [57] The benefits of incorporating an exercise regimen have shown the best results when paced accordingly. [58]

Meditation may also be helpful in the treatment of panic disorders. [59]

Muscle relaxation techniques are useful to some individuals. These can be learned using recordings, videos, or books. While muscle relaxation has proved to be less effective than cognitive-behavioral therapies in controlled trials, many people still find at least temporary relief from muscle relaxation. [23]

Breathing exercises

In the great majority of cases, hyperventilation is involved, exacerbating the effects of the panic attack. Breathing retraining exercise helps to rebalance the oxygen and CO2 levels in the blood. [60]

David D. Burns recommends breathing exercises for those with anxiety. One such breathing exercise is a 5-2-5 count. Using the stomach (or diaphragm)—and not the chest—inhale (feel the stomach come out, as opposed to the chest expanding) for 5 seconds. As the maximal point at inhalation is reached, hold the breath for 2 seconds. Then slowly exhale, over 5 seconds. Repeat this cycle twice and then breathe 'normally' for 5 cycles (1 cycle = 1 inhale + 1 exhale). The point is to focus on breathing and relax the heart rate. Regular diaphragmatic breathing may be achieved by extending the out-breath by counting or humming. [61]

Although breathing into a paper bag was a common recommendation for short-term treatment of symptoms of an acute panic attack, [62] it has been criticized as inferior to measured breathing, potentially worsening the panic attack and possibly reducing needed blood oxygen. [63] [64] While the paper bag technique increases needed carbon dioxide and so reduces symptoms, it may excessively lower oxygen levels in the bloodstream.

Capnometry, which provides exhaled CO2 levels, may help guide breathing. [65] [66]

Therapy

According to the American Psychological Association, "most specialists agree that a combination of cognitive and behavioral therapies are the best treatment for panic disorder. Medication might also be appropriate in some cases." [67] The first part of therapy is largely informational; many people are greatly helped by simply understanding exactly what panic disorder is and how many others experience it. Many people with panic disorder are worried that their panic attacks mean they are "going crazy" or that the panic might induce a heart attack. Cognitive restructuring helps people to replace those thoughts with more realistic, positive ways of viewing the attacks. [68] Avoidant behavior is one of the key aspects that prevent people with frequent panic attacks from functioning healthily. [23] Exposure therapy, [69] which includes repeated and prolonged confrontation with feared situations and body sensations, helps weaken anxiety responses to panic-inducing external and internal stimuli and reinforce realistic ways of viewing panic symptoms.

In deeper-level psychoanalytic approaches, in particular object relations theory, panic attacks are frequently associated with splitting (psychology), paranoid-schizoid and depressive positions, and paranoid anxiety. They are often found to be comorbid with borderline personality disorder and child sexual abuse. Paranoid anxiety may reach the level of a persecutory anxiety state. [70]

There was a meta-analysis of the comorbidity of panic disorders and agoraphobia. It used exposure therapy to treat patients over a period. Hundreds of patients were used in these studies and they all met the DSM-IV criteria for both of these disorders. [71] A result was that thirty-two percent of patients had a panic episode after treatment. They concluded that the use of exposure therapy has lasting efficacy for a client who is living with a panic disorder and agoraphobia. [71]

The efficacy of group therapy treatment over conventional individual therapy for people with panic disorder with or without agoraphobia appears similar. [72]

Medication

Medication options for panic attacks typically include benzodiazepines and antidepressants. Benzodiazepines are being prescribed less often because of their potential side effects, such as dependence, fatigue, slurred speech, and memory loss. [73] Antidepressant treatments for panic attacks include selective serotonin reuptake inhibitors (SSRIs), serotonin noradrenaline reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), and MAO inhibitors (MAOIs). SSRIs in particular tend to be the first drug treatment used to treat panic attacks. Selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants appear similar for short-term efficacy. [74]

SSRIs carry a relatively low risk since they are not associated with much tolerance or dependence, and are difficult to overdose with. TCAs are similar to SSRIs in their many advantages but come with more common side effects such as weight gain and cognitive disturbances. They are also easier to overdose on. MAOIs are generally suggested for patients who have not responded to other forms of treatment. [75]

While the use of drugs in treating panic attacks can be very successful, it is generally recommended that people also be in some form of therapy, such as cognitive-behavioral therapy. Drug treatments are usually used throughout the duration of panic attack symptoms and discontinued after the patient has been free of symptoms for at least six months. It is usually safest to withdraw from these drugs gradually while undergoing therapy. [23] While drug treatment seems promising for children and adolescents, they are at an increased risk of suicide while taking these medications and their well-being should be monitored closely. [75]

Prognosis

Roughly one-third are treatment-resistant. [76] These people continue to have panic attacks and various other panic disorder symptoms after receiving treatment. [76]

Many people being treated for panic attacks begin to experience limited symptom attacks. These panic attacks are less comprehensive, with fewer than four bodily symptoms being experienced. [14]

It is not unusual to experience only one or two symptoms at a time, such as vibrations in their legs, shortness of breath, or an intense wave of heat traveling up their bodies, which is not similar to hot flashes due to estrogen shortage. Some symptoms, such as vibrations in the legs, are sufficiently different from any normal sensation that they indicate a panic disorder. Other symptoms on the list can occur in people who may or may not have panic disorder. Panic disorder does not require four or more symptoms to all be present at the same time. Causeless panic and racing heartbeat are sufficient to indicate a panic attack. [14]

Epidemiology

In Europe, about 3% of the population has a panic attack in a given year while in the United States they affect about 11%. [2] They are more common in females than in males. [2] They often begin during puberty or early adulthood. [2] Children and older people are less commonly affected. [2] A meta-analysis was conducted on data collected about twin studies and family studies on the link between genes and panic disorder. The researchers also examined the possibility of a link to phobias, obsessive-compulsive disorder (OCD), and generalized anxiety disorder. The researchers used a database called MEDLINE to accumulate their data. [77] The results concluded that the aforementioned disorders have a genetic component and are inherited or passed down through genes. For the non-phobias, the likelihood of inheriting is 30–40%, and for the phobias, it was 50–60%. [77]

See also

Related Research Articles

<span class="mw-page-title-main">Anxiety</span> Unpleasant state of inner turmoil over anticipated events

Anxiety is an emotion which is characterised by an unpleasant state of inner turmoil and includes feelings of dread over anticipated events. Anxiety is different from fear in that fear is defined as the emotional response to a real threat, whereas anxiety is the anticipation of a future threat. It is often accompanied by nervous behavior such as pacing back and forth, somatic complaints, and rumination.

<span class="mw-page-title-main">Antidepressant</span> Class of medication used to treat depression and other conditions

Antidepressants are a class of medications used to treat major depressive disorder, anxiety disorders, chronic pain, and addiction.

An anxiolytic is a medication or other intervention that reduces anxiety. This effect is in contrast to anxiogenic agents which increase anxiety. Anxiolytic medications are used for the treatment of anxiety disorders and their related psychological and physical symptoms.

<span class="mw-page-title-main">Phobia</span> Anxiety disorder classified by a persistent and excessive fear of an object or situation

A phobia is an anxiety disorder, defined by a persistent and excessive fear of an object or situation. Phobias typically result in a rapid onset of fear and are usually present for more than six months. Those affected go to great lengths to avoid the situation or object, to a degree greater than the actual danger posed. If the object or situation cannot be avoided, they experience significant distress. Other symptoms can include fainting, which may occur in blood or injury phobia, and panic attacks, often found in agoraphobia and emetophobia. Around 75% of those with phobias have multiple phobias.

<span class="mw-page-title-main">Anxiety disorder</span> Cognitive disorder with an excessive, irrational dread of everyday situations

Anxiety disorders are a cluster of mental disorders characterized by significant and uncontrollable feelings of anxiety and fear such that a person's social, occupational, and personal functions are significantly impaired. Anxiety may cause physical and cognitive symptoms, such as restlessness, irritability, easy fatigue, difficulty concentrating, increased heart rate, chest pain, abdominal pain, and a variety of other symptoms that may vary based on the individual.

<span class="mw-page-title-main">Agoraphobia</span> Anxiety disorder

Agoraphobia is a mental and behavioral disorder, specifically an anxiety disorder characterized by symptoms of anxiety in situations where the person perceives their environment to be unsafe with no easy way to escape. These situations can include public transit, shopping centers, crowds and queues, or simply being outside their home on their own. Being in these situations may result in a panic attack. Those affected will go to great lengths to avoid these situations. In severe cases, people may become completely unable to leave their homes.

Specific phobia is an anxiety disorder, characterized by an extreme, unreasonable, and irrational fear associated with a specific object, situation, or concept which poses little or no actual danger. Specific phobia can lead to avoidance of the object or situation, persistence of the fear, and significant distress or problems functioning associated with the fear. A phobia can be the fear of anything.

<span class="mw-page-title-main">Paroxetine</span> SSRI antidepressant medication

Paroxetine, sold under the brand names Paxil and Seroxat among others, is an antidepressant of the selective serotonin reuptake inhibitor (SSRI) class. It is used to treat major depressive disorder, obsessive-compulsive disorder, panic disorder, social anxiety disorder, post-traumatic stress disorder, generalized anxiety disorder, and premenstrual dysphoric disorder. It has also been used in the treatment of premature ejaculation and hot flashes due to menopause. It is taken orally.

<span class="mw-page-title-main">Hypochondriasis</span> Medical condition

Hypochondriasis or hypochondria is a condition in which a person is excessively and unduly worried about having a serious illness. Hypochondria is an old concept whose meaning has repeatedly changed over its lifespan. It has been claimed that this debilitating condition results from an inaccurate perception of the condition of body or mind despite the absence of an actual medical diagnosis. An individual with hypochondriasis is known as a hypochondriac. Hypochondriacs become unduly alarmed about any physical or psychological symptoms they detect, no matter how minor the symptom may be, and are convinced that they have, or are about to be diagnosed with, a serious illness.

Hyperventilation syndrome (HVS), also known as chronic hyperventilation syndrome (CHVS), dysfunctional breathing hyperventilation syndrome, cryptotetany, spasmophilia, latent tetany, and central neuronal hyper excitability syndrome (NHS), is a respiratory disorder, psychologically or physiologically based, involving breathing too deeply or too rapidly (hyperventilation). HVS may present with chest pain and a tingling sensation in the fingertips and around the mouth (paresthesia) and may accompany a panic attack.

Generalized anxiety disorder (GAD) is a mental and behavioral disorder, specifically an anxiety disorder characterized by excessive, uncontrollable and often irrational worry about events or activities. Worry often interferes with daily functioning, and individuals with GAD are often overly concerned about everyday matters such as health, finances, death, family, relationship concerns, or work difficulties. Symptoms may include excessive worry, restlessness, trouble sleeping, exhaustion, irritability, sweating, and trembling.

Biological psychiatry or biopsychiatry is an approach to psychiatry that aims to understand mental disorder in terms of the biological function of the nervous system. It is interdisciplinary in its approach and draws on sciences such as neuroscience, psychopharmacology, biochemistry, genetics, epigenetics and physiology to investigate the biological bases of behavior and psychopathology. Biopsychiatry is the branch of medicine which deals with the study of the biological function of the nervous system in mental disorders.

<span class="mw-page-title-main">Hallucinogen persisting perception disorder</span> Medical condition

Hallucinogen persisting perception disorder (HPPD) is a non-psychotic disorder in which a person experiences apparent lasting or persistent visual hallucinations or perceptual distortions after a previous use of drugs, including but not limited to psychedelics, dissociatives, entactogens, tetrahydrocannabinol (THC), and SSRIs. Despite being designated as a hallucinogen-specific disorder, the specific contributory role of psychedelic drugs is unknown.

Antidepressant discontinuation syndrome, also called antidepressant withdrawal syndrome, is a condition that can occur following the interruption, reduction, or discontinuation of antidepressant medication following its continuous use of at least a month. The symptoms may include flu-like symptoms, trouble sleeping, nausea, poor balance, sensory changes, akathisia, intrusive thoughts, depersonalization and derealization, mania, anxiety, and depression. The problem usually begins within three days and may last for several weeks or months. Rarely psychosis may occur.

<span class="mw-page-title-main">Depression in childhood and adolescence</span> Pediatric depressive disorders

Major depressive disorder, often simply referred to as depression, is a mental disorder characterized by prolonged unhappiness or irritability. It is accompanied by a constellation of somatic and cognitive signs and symptoms such as fatigue, apathy, sleep problems, loss of appetite, loss of engagement, low self-regard/worthlessness, difficulty concentrating or indecisiveness, or recurrent thoughts of death or suicide.

<span class="mw-page-title-main">Social anxiety disorder</span> Anxiety disorder associated with social situations

Social anxiety disorder (SAD), also known as social phobia, is an anxiety disorder characterized by sentiments of fear and anxiety in social situations, causing considerable distress and impairing ability to function in at least some aspects of daily life. These fears can be triggered by perceived or actual scrutiny from others. Individuals with social anxiety disorder fear negative evaluations from other people.

<span class="mw-page-title-main">Selective serotonin reuptake inhibitor</span> Class of antidepressant medication

Selective serotonin reuptake inhibitors (SSRIs) are a class of drugs that are typically used as antidepressants in the treatment of major depressive disorder, anxiety disorders, and other psychological conditions.

<span class="mw-page-title-main">Panic disorder</span> Anxiety disorder characterized by reoccurring unexpected panic attacks

Panic disorder is a mental and behavioral disorder, specifically an anxiety disorder characterized by reoccurring unexpected panic attacks. Panic attacks are sudden periods of intense fear that may include palpitations, sweating, shaking, shortness of breath, numbness, or a feeling that something terrible is going to happen. The maximum degree of symptoms occurs within minutes. There may be ongoing worries about having further attacks and avoidance of places where attacks have occurred in the past.

Autophobia, also called monophobia, isolophobia, or eremophobia, is the specific phobia or a morbid fear or dread of oneself or of being alone, isolated, abandoned, and ignored. This specific phobia is associated with the idea of being alone, often causing severe anxiety.

Future tripping, also referred to as anticipatory anxiety, describes a type of fear that occurs when an anticipated event in the future causes distress. These events can include both major occasions, such as a presentation, but depending on the individual could also happen before some minor event, like going out. It is not seen as a distinct type of anxiety but rather plays a part in many variations and can be found in numerous disorders and is strongly connected to panic attacks, often following them.

References

  1. 1 2 "Anxiety Disorders". NIMH. March 2016. Archived from the original on 29 September 2016. Retrieved 1 October 2016.
  2. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 American Psychiatric Association (2013), Diagnostic and Statistical Manual of Mental Disorders (5th ed.), Arlington: American Psychiatric Publishing, pp.  214–217, ISBN   978-0-89042-555-8
  3. 1 2 Bandelow, Borwin; Domschke, Katharina; Baldwin, David (2013). Panic Disorder and Agoraphobia. OUP Oxford. p. Chapter 1. ISBN   978-0-19-100426-1. Archived from the original on 20 December 2016.
  4. 1 2 Craske, Michelle G; Stein, Murray B (December 2016). "Anxiety". The Lancet. 388 (10063): 3048–3059. doi:10.1016/S0140-6736(16)30381-6. PMID   27349358. S2CID   208789585.
  5. 1 2 "Panic Disorder: When Fear Overwhelms". NIMH. 2022. Archived from the original on March 23, 2022. Retrieved March 18, 2022.
  6. 1 2 3 Geddes, John; Price, Jonathan; McKnight, Rebecca (2012). Psychiatry. OUP Oxford. p. 298. ISBN   978-0-19-923396-0. Archived from the original on 4 October 2016.
  7. Lo, Yu-Chi; Chen, Hsi-Han (May 2020). "Shiau-Shian Huang Panic Disorder Correlates with the Risk for Sexual Dysfunction". Journal of Psychiatric Practice . 26 (3): 185–200. doi:10.1097/PRA.0000000000000460. PMID   32421290. S2CID   218643956.
  8. Smith, Melinda; Robinson, Lawrence; Segal, Jeanne. "Panic Attacks and Panic Disorder". HelpGuide. Archived from the original on 2021-07-09. Retrieved 2021-07-06.
  9. Ghadri, Jelena-Rima; Wittstein, Ilan Shor; Prasad, Abhiram; Sharkey, Scott; Dote, Keigo; Akashi, Yoshihiro John; Cammann, Victoria Lucia; Crea, Filippo; Galiuto, Leonarda; Desmet, Walter; Yoshida, Tetsuro; Manfredini, Roberto; Eitel, Ingo; Kosuge, Masami; Nef, Holger M; Deshmukh, Abhishek; Lerman, Amir; Bossone, Eduardo; Citro, Rodolfo; Ueyama, Takashi; Corrado, Domenico; Kurisu, Satoshi; Ruschitzka, Frank; Winchester, David; Lyon, Alexander R; Omerovic, Elmir; Bax, Jeroen J; Meimoun, Patrick; Tarantini, Guiseppe; Rihal, Charanjit; Y.-Hassan, Shams; Migliore, Federico; Horowitz, John D; Shimokawa, Hiroaki; Lüscher, Thomas Felix; Templin, Christian (7 June 2018). "International Expert Consensus Document on Takotsubo Syndrome (Part I): Clinical Characteristics, Diagnostic Criteria, and Pathophysiology". European Heart Journal. 39 (22): 2032–2046. doi:10.1093/eurheartj/ehy076. PMC   5991216 . PMID   29850871.
  10. American Psychiatric Association, American Psychiatric Association. "Changes to the DSM-V to the DSM-V-TR" (PDF). Changes to the DSM V to DSM V-TR. Archived (PDF) from the original on 2 September 2018. Retrieved 22 March 2022.
  11. Stewart, Julian M.; Pianosi, Paul; Shaban, Mohamed A.; Terilli, Courtney; Svistunova, Maria; Visintainer, Paul; Medow, Marvin S. (2018-11-01). "Hemodynamic characteristics of postural hyperventilation: POTS with hyperventilation versus panic versus voluntary hyperventilation". Journal of Applied Physiology. 125 (5): 1396–1403. doi: 10.1152/japplphysiol.00377.2018 . ISSN   8750-7587. PMC   6442665 . PMID   30138078.
  12. Roth, Walton T. (January 2010). "Diversity of effective treatments of panic attacks: what do they have in common?". Depression and Anxiety. 27 (1): 5–11. doi: 10.1002/da.20601 . PMID   20049938. S2CID   31719106.
  13. "Symptoms and causes - Mayo Clinic". www.mayoclinic.org. Archived from the original on 2022-03-17. Retrieved 2022-03-17.
  14. 1 2 3 4 5 6 Bourne, E. (2005). The Anxiety and Phobia Workbook, 4th Edition: New Harbinger Press.[ page needed ]
  15. "Panic disorder: MedlinePlus Medical Encyclopedia". medlineplus.gov. Archived from the original on 2023-06-08. Retrieved 2022-03-14.
  16. Klerman, Gerald L.; Hirschfeld, Robert M. A.; Weissman, Myrna M. (1993). Panic Anxiety and Its Treatments: Report of the World Psychiatric Association Presidential Educational Program Task Force. American Psychiatric Association. p.  44. ISBN   978-0-88048-684-2.
  17. "Panic Disorder | Anxiety and Depression". adaa.org. Archived from the original on 2023-03-12. Retrieved 2023-03-12.
  18. Cosci, Fiammetta (June 2012). "The psychological development of panic disorder: implications for neurobiology and treatment". Revista Brasileira de Psiquiatria. 34: S09–S31. doi: 10.1590/s1516-44462012000500003 . PMID   22729447.
  19. Marquardt, David Z. Hambrick, Madeline (March 2018). "Bad News for the Highly Intelligent". Scientific American. Archived from the original on 2021-01-27. Retrieved 2021-01-26.{{cite web}}: CS1 maint: multiple names: authors list (link)
  20. Gregory a. Leskin, PhD (January 2004). "Gender Differences in Panic Disorder". Psychiatric Times. Psychiatric Times Vol 21 No 1. 21 (1). Archived from the original on 2021-01-23. Retrieved 2021-01-26.
  21. Davies, Matthew N.; Verdi, Serena; Burri, Andrea; Trzaskowski, Maciej; Lee, Minyoung; Hettema, John M.; Jansen, Rick; Boomsma, Dorret I.; Spector, Tim D. (14 August 2015). "Generalised Anxiety Disorder – A Twin Study of Genetic Architecture, Genome-Wide Association and Differential Gene Expression". PLOS ONE. 10 (8): e0134865. Bibcode:2015PLoSO..1034865D. doi: 10.1371/journal.pone.0134865 . PMC   4537268 . PMID   26274327.
  22. Nolen-Hoeksema, Susan (2013). (Ab)normal Psychology (6th ed.). McGraw Hill. ISBN   978-0-07-803538-8.[ page needed ]
  23. 1 2 3 4 Taylor, C Barr (22 April 2006). "Panic disorder". BMJ. 332 (7547): 951–955. doi:10.1136/bmj.332.7547.951. PMC   1444835 . PMID   16627512.
  24. William T. O‘Donohue,· Lorraine T. Benuto, Lauren Woodward Tolle (eds, 2013). Handbook of Adolescent Health Psychology, Springer, New York. ISBN   978-1-4614-6632-1. Page 511
  25. Maddock, Richard J.; Carter, Cameron S. (May 1991). "Hyperventilation-induced panic attacks in panic disorder with agoraphobia". Biological Psychiatry. 29 (9): 843–854. doi:10.1016/0006-3223(91)90051-m. PMID   1904781. S2CID   36334143.
  26. "Medical marijuana and the mind - Harvard Health". Archived from the original on 21 August 2016. Retrieved 2016-08-14.
  27. Zvolensky, Michael J.; Gonzalez, Adam; Bonn-Miller, Marcel O.; Bernstein, Amit; Goodwin, Renee D. (February 2008). "Negative reinforcement/negative affect reduction cigarette smoking outcome expectancies: Incremental validity for anxiety focused on bodily sensations and panic attack symptoms among daily smokers". Experimental and Clinical Psychopharmacology. 16 (1): 66–76. doi:10.1037/1064-1297.16.1.66. PMID   18266553.
  28. Gorman, JM; Kent, JM; Sullivan, GM; Coplan, JD (April 2000). "Neuroanatomical hypothesis of panic disorder, revised". The American Journal of Psychiatry. 157 (4): 493–505. doi:10.1176/appi.ajp.157.4.493. PMID   10739407.
  29. Panic Disorder – familydoctor.org Archived 3 February 2014 at the Wayback Machine
  30. "Anxiety Disorders" Archived 12 April 2014 at the Wayback Machine
  31. Inglis, Sally C; Clark, Robyn A; Dierckx, Riet; Prieto-Merino, David; Cleland, John GF (31 October 2015). "Structured telephone support or non-invasive telemonitoring for patients with heart failure". Cochrane Database of Systematic Reviews. 2015 (10): CD007228. doi:10.1002/14651858.CD007228.pub3. hdl: 2328/35732 . PMC   8482064 . PMID   26517969.
  32. "Agoraphobia". MayoClinic.com. 21 April 2011. Archived from the original on 24 June 2012. Retrieved 2012-06-15.
  33. Bowker, Julie C.; Bowker, Matthew H.; Santo, Jonathan B.; Ojo, Adesola Adebusola; Etkin, Rebecca G.; Raja, Radhi (2019-09-03). "Severe Social Withdrawal: Cultural Variation in Past Hikikomori Experiences of University Students in Nigeria, Singapore, and the United States". The Journal of Genetic Psychology. 180 (4–5): 217–230. doi:10.1080/00221325.2019.1633618. ISSN   0022-1325. PMID   31305235. S2CID   196616453.
  34. Emiko Jozuka (2016-09-12). "Why won't 541,000 young Japanese leave the house?". CNN Digital. Archived from the original on 2021-03-06. Retrieved 2021-01-26.
  35. Perugi, Giulio; Frare, Franco; Toni, Cristina (2007). "Diagnosis and treatment of agoraphobia with panic disorder". CNS Drugs. 21 (9): 741–764. doi:10.2165/00023210-200721090-00004. ISSN   1172-7047. PMID   17696574. S2CID   43437233. Archived from the original on 2021-02-24. Retrieved 2021-02-03.
  36. Leicht, Gregor; Mulert, Christoph; Eser, Daniela; Sämann, Philipp G.; Ertl, Matthias; Laenger, Anna; Karch, Susanne; Pogarell, Oliver; Meindl, Thomas; Czisch, Michael; Rupprecht, Rainer (2013). "Benzodiazepines Counteract Rostral Anterior Cingulate Cortex Activation Induced by Cholecystokinin-Tetrapeptide in Humans". Biological Psychiatry. 73 (4): 337–44. doi:10.1016/j.biopsych.2012.09.004. PMID   23059050. S2CID   23586549.
  37. Moreira, Fabrício A.; Gobira, Pedro H.; Viana, Thércia G.; Vicente, Maria A.; Zangrossi, Hélio; Graeff, Frederico G. (2013). "Modeling panic disorder in rodents". Cell and Tissue Research. 354 (1): 119–25. doi:10.1007/s00441-013-1610-1. PMID   23584609. S2CID   14699738.
  38. 1 2 3 4 5 Bystritsky, Alexander; Khalsa, Sahib S.; Cameron, Michael E.; Schiffman, Jason (2013). "Current Diagnosis and Treatment of Anxiety Disorders". Pharmacy and Therapeutics. 38 (1): 30–57. PMC   3628173 . PMID   23599668.
  39. Montoya, Alonso; Bruins, Robert; Katzman, Martin A; Blier, Pierre (1 March 2016). "The noradrenergic paradox: implications in the management of depression and anxiety". Neuropsychiatric Disease and Treatment. 12: 541–557. doi: 10.2147/NDT.S91311 . PMC   4780187 . PMID   27042068.
  40. Vollmer, L L; Strawn, J R; Sah, R (May 2015). "Acid–base dysregulation and chemosensory mechanisms in panic disorder: a translational update". Translational Psychiatry. 5 (5): e572. doi:10.1038/tp.2015.67. PMC   4471296 . PMID   26080089.
  41. Ueda, Y.; Aizawa, M.; Takahashi, A.; Fujii, M.; Isaka, Y. (8 October 2008). "Exaggerated compensatory response to acute respiratory alkalosis in panic disorder is induced by increased lactic acid production". Nephrology Dialysis Transplantation. 24 (3): 825–828. doi: 10.1093/ndt/gfn585 . PMID   18940883.
  42. Cipolla, Marilyn J. (2009). Control of Cerebral Blood Flow. Morgan & Claypool Life Sciences. Archived from the original on 2020-09-28. Retrieved 2017-10-04.
  43. Nardi, Antonio Egidio; Freire, Rafael Christophe R. (2016-05-25). Panic Disorder: Neurobiological and Treatment Aspects. Springer. ISBN   978-3-319-12538-1. Archived from the original on 2023-12-30. Retrieved 2020-10-27.
  44. Shin, Lisa M; Liberzon, Israel (January 2010). "The Neurocircuitry of Fear, Stress, and Anxiety Disorders". Neuropsychopharmacology. 35 (1): 169–191. doi:10.1038/npp.2009.83. PMC   3055419 . PMID   19625997.
  45. Maren, Stephen (November 2009). "An Acid-Sensing Channel Sows Fear and Panic". Cell. 139 (5): 867–869. doi:10.1016/j.cell.2009.11.008. hdl: 2027.42/83231 . PMID   19945375. S2CID   18322284.
  46. PhD, Andrew M. Leeds (2016-02-03). A Guide to the Standard EMDR Therapy Protocols for Clinicians, Supervisors, and Consultants, Second Edition. Springer Publishing Company. ISBN   978-0-8261-3117-1. Archived from the original on 2023-12-30. Retrieved 2020-10-27.
  47. 1 2 Chalmers, John A.; Quintana, Daniel S.; Abbott, Maree J.-Anne; Kemp, Andrew H. (11 July 2014). "Anxiety Disorders are Associated with Reduced Heart Rate Variability: A Meta-Analysis". Frontiers in Psychiatry. 5: 80. doi: 10.3389/fpsyt.2014.00080 . PMC   4092363 . PMID   25071612.
  48. 1 2 Soares-Filho, Gastao L. F.; Arias-Carrion, Oscar; Santulli, Gaetano; Silva, Adriana C.; Machado, Sergio; Nardi, Alexandre M. Valenca and Antonio E.; Nardi, AE (31 July 2014). "Chest Pain, Panic Disorder and Coronary Artery Disease: A Systematic Review". CNS & Neurological Disorders Drug Targets. 13 (6): 992–1001. doi:10.2174/1871527313666140612141500. PMID   24923348.
  49. 1 2 Rockville (MD), Substance Abuse and Mental Health Services Administration. (June 2016). "Table 3.10, Panic Disorder and Agoraphobia Criteria Changes from DSM-IV to DSM-5". www.ncbi.nlm.nih.gov. Archived from the original on 2023-03-07. Retrieved 2023-03-14.
  50. Houck, P. R.; Spiegel, D. A.; Shear, M. K.; Rucci, P. (2002). "Reliability of the self-report version of the Panic Disorder Severity Scale". Depression and Anxiety. 15 (4): 183–185. doi:10.1002/da.10049. PMID   12112724. S2CID   25176812.
  51. Shear, M. K.; Rucci, P.; Williams, J.; Frank, E.; Grochocinski, V.; Vander Bilt, J.; Houck, P.; Wang, T. (2001). "Reliability and validity of the Panic Disorder Severity Scale: Replication and extension". Journal of Psychiatric Research. 35 (5): 293–296. doi:10.1016/S0022-3956(01)00028-0. PMID   11591432.
  52. "Panic disorder: MedlinePlus Medical Encyclopedia". medlineplus.gov. Archived from the original on 2023-06-08. Retrieved 2023-03-12.
  53. Generalised anxiety disorder and panic disorder in adults: management. Clinical Guideline 113. National Institute for Health and Care Excellence. 26 July 2019. ISBN   978-1-4731-2854-5. Archived from the original on 22 November 2018. Retrieved 8 January 2021.
  54. Bandelow, Borwin; Seidler-Brandler, Ulrich; Becker, Andreas; Wedekind, Dirk; Rüther, Eckart (January 2007). "Meta-analysis of randomized controlled comparisons of psychopharmacological and psychological treatments for anxiety disorders". The World Journal of Biological Psychiatry. 8 (3): 175–187. doi:10.1080/15622970601110273. PMID   17654408. S2CID   8504020.
  55. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev., p. 479). Washington, D.C.: American Psychiatric Association.[ page needed ]
  56. "3 Tips for Using Exercise to Shrink Anxiety". 2013-07-17. Archived from the original on 20 April 2015. Retrieved 2015-04-14.[ full citation needed ]
  57. MedlinePlus Encyclopedia : Hyperventilation
  58. "Cardio Exercise for Beginners". Archived from the original on 23 April 2015. Retrieved 2015-04-14.[ full citation needed ]
  59. Kabat-Zinn, J; Massion, AO; Kristeller, J; Peterson, LG; Fletcher, KE; Pbert, L; Lenderking, WR; Santorelli, SF (July 1992). "Effectiveness of a meditation-based stress reduction program in the treatment of anxiety disorders". American Journal of Psychiatry. 149 (7): 936–943. CiteSeerX   10.1.1.474.4968 . doi:10.1176/ajp.149.7.936. PMID   1609875.
  60. "Hyperventilation Syndrome". 28 November 2016. Archived from the original on 13 July 2017. Retrieved 2017-09-18.
  61. Bhagat, Vidya; Haque2, Mainul; Jaalam3, Kamarudin (2017). "Breathing Exercise - A Commanding Tool for Self-help Management during Panic attacks". Research Journal of Pharmacy and Technology, 10(12), 4471-4473. 10 (12): 4471–4473.{{cite journal}}: CS1 maint: numeric names: authors list (link)
  62. Breathing in and out of a paper bag Archived 21 October 2007 at the Wayback Machine
  63. Bergeron, J. David; Le Baudour, Chris (2009). "Chapter 9: Caring for Medical Emergencies". First Responder (8 ed.). New Jersey: Pearson Prentice Hall. p. 262. ISBN   978-0-13-614059-7. Do not use a paper bag in an attempt to treat hyperventilation. These patients can often be cared for with low-flow oxygen and lots of reassurance
  64. Hyperventilation Syndrome – Can I treat hyperventilation syndrome by breathing into a paper bag? Archived 20 January 2013 at the Wayback Machine
  65. Craske, Michelle (30 September 2011). "Psychotherapy for panic disorder". Archived from the original on 14 October 2017. Retrieved 29 April 2020.
  66. Meuret, Alicia E.; Ritz, Thomas (October 2010). "Hyperventilation in panic disorder and asthma: Empirical evidence and clinical strategies". International Journal of Psychophysiology. 78 (1): 68–79. doi:10.1016/j.ijpsycho.2010.05.006. PMC   2937087 . PMID   20685222.
  67. "Answers to Your Questions About Panic Disorder". American Psychological Association. 2008. Archived from the original on 2021-01-10. Retrieved 2021-01-08.
  68. Cramer, K., Post, T., & Behr, M. (January 1989). "Cognitive Restructuring Ability, Teacher Guidance and Perceptual Distracter Tasks: An Aptitude Treatment Interaction Study". Archived from the original on 22 December 2010. Retrieved 2010-11-19.{{cite web}}: CS1 maint: multiple names: authors list (link)
  69. Abramowitz, Jonathan S.; Deacon, Brett J.; Whiteside, Stephen P. H. (17 December 2012). Exposure Therapy for Anxiety: Principles and Practice. Guilford Press. ISBN   978-1-4625-0969-0. Archived from the original on 20 May 2016.
  70. Waska, Robert (2010). Treating Severe Depressive and Persecutory Anxiety States: To Transform the Unbearable. Karnac Books. ISBN   978-1855757202.[ page needed ]
  71. 1 2 Fava, G. A.; Rafanelli, C.; Grandi, S.; Conti, S.; Ruini, C.; Mangelli, L.; Belluardo, P. (July 2001). "Long-term outcome of panic disorder with agoraphobia treated by exposure". Psychological Medicine. 31 (5): 891–898. doi:10.1017/s0033291701003592. PMID   11459386. S2CID   5652068.
  72. Schwartze, Dominique; Barkowski, Sarah; Strauss, Bernhard; Burlingame, Gary M.; Barth, Jürgen; Rosendahl, Jenny (June 2017). "Efficacy of group psychotherapy for panic disorder: Meta-analysis of randomized, controlled trials". Group Dynamics: Theory, Research, and Practice. 21 (2): 77–93. doi:10.1037/gdn0000064. S2CID   152168481.
  73. Batelaan, Neeltje M.; Van Balkom, Anton J. L. M.; Stein, Dan J. (April 2012). "Evidence-based pharmacotherapy of panic disorder: an update". The International Journal of Neuropsychopharmacology. 15 (3): 403–415. doi: 10.1017/S1461145711000800 . hdl: 1871/42311 . PMID   21733234.
  74. Bakker, A.; Van Balkom, A. J. L. M.; Spinhoven, P. (2002). "SSRIs vs. TCAs in the treatment of panic disorder: a meta-analysis". Acta Psychiatrica Scandinavica. 106 (3): 163–167. doi:10.1034/j.1600-0447.2002.02255.x. PMID   12197851. S2CID   26184300.
  75. 1 2 Marchesi, Carlo (March 2008). "Pharmacological management of panic disorder". Neuropsychiatric Disease and Treatment. 4 (1): 93–106. doi: 10.2147/ndt.s1557 . PMC   2515914 . PMID   18728820.
  76. 1 2 Freire, Rafael C.; Zugliani, Morena M.; Garcia, Rafael F.; Nardi, Antonio E. (22 January 2016). "Treatment–resistant panic disorder: a systematic review". Expert Opinion on Pharmacotherapy. 17 (2): 159–168. doi:10.1517/14656566.2016.1109628. PMID   26635099. S2CID   9242842.
  77. 1 2 Hettema, John M.; Neale, Michael C.; Kendler, Kenneth S. (October 2001). "A Review and Meta-Analysis of the Genetic Epidemiology of Anxiety Disorders". American Journal of Psychiatry. 158 (10): 1568–1578. doi:10.1176/appi.ajp.158.10.1568. PMID   11578982. S2CID   7865025.