Panic disorder

Panic disorder
Depiction of someone with a panic attack, being reassured by another person
Specialty	Psychiatry, clinical psychology
Symptoms	Sudden periods of intense fear, palpitations, sweating, shaking, shortness of breath, numbness [1] [2]
Usual onset	Sudden and recurrent [1]
Causes	Unknown [3]
Risk factors	Family history, smoking, psychological stress, history of child abuse [2]
Diagnostic method	Based on symptoms after ruling out other potential causes [2] [3]
Differential diagnosis	Heart disease, hyperthyroidism, drug use [2] [3]
Treatment	Counselling, medications [3]
Medication	Antidepressants, benzodiazepines, beta blockers [1] [3]
Frequency	2.5% of people at some point [4]

Panic disorder is a mental and behavioral disorder, ^[5] specifically an anxiety disorder characterized by reoccurring unexpected panic attacks. ^[1] 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. ^{[1] [2]} The maximum degree of symptoms occurs within minutes. ^[2] There may be ongoing worries about having further attacks and avoidance of places where attacks have occurred in the past. ^[1]

The cause of panic disorder is unknown. ^[3] Panic disorder often runs in families. ^[3] Risk factors include smoking, psychological stress, and a history of child abuse. ^[2] Diagnosis involves ruling out other potential causes of anxiety including other mental disorders, medical conditions such as heart disease or hyperthyroidism, and drug use. ^{[2] [3]} Screening for the condition may be done using a questionnaire. ^[6]

Panic disorder is usually treated with counselling and medications. ^[3] The type of counselling used is typically cognitive behavioral therapy (CBT) which is effective in more than half of people. ^{[3] [4]} Medications used include antidepressants, benzodiazepines, and beta blockers. ^{[1] [3]} Following stopping treatment up to 30% of people have a recurrence. ^[4]

Panic disorder affects about 2.5% of people at some point in their life. ^[4] It usually begins during adolescence or early adulthood, but may affect people of any age. ^[3] It is less common in children and elderly people. ^[2] Women are more likely than men to develop panic disorder. ^[3]

Signs and symptoms

Individuals with panic disorder usually have a series of intense episodes of extreme anxiety during panic attacks. These attacks typically last about ten minutes, and can be as short-lived as 1–5 minutes, but can last twenty minutes to more than an hour, or until helpful intervention is made. Panic attacks can last up to an hour, and the intensity and symptoms of panic may vary. ^[7]

In some cases, the attack may continue at unabated high intensity or seem to be increasing in severity. Managing panic disorder can be a challenge, but there are several strategies that can help individuals manage their symptoms and improve their social life. Common symptoms of panic disorder attack include rapid heartbeat, perspiration, dizziness, dyspnea, trembling, uncontrollable fear such as: the fear of losing control and going crazy, ^[8] the fear of dying ^[9] and hyperventilation. Other symptoms are a sensation of choking, paralysis, chest pain, nausea, numbness or tingling, chills or hot flashes, vision problems, faintness, crying ^[10] and some sense of altered reality. ^[11] In addition, the person usually has thoughts of impending doom. ^[12] Individuals experiencing an episode have often a strong wish of escaping from the situation that provoked the attack. The anxiety of panic disorder is particularly severe and noticeably episodic compared to that from generalized anxiety disorder. Panic attacks may be provoked by exposure to certain stimuli (e.g., seeing a mouse) or settings (e.g., the dentist's office). ^[11] Nocturnal panic attacks are common in people with panic disorder. ^[13] Other attacks may appear unprovoked. Some individuals deal with these events on a regular basis, sometimes daily or weekly.

Limited symptom attacks are similar to panic attacks but have fewer symptoms. Most people with Parkinson's disease experience both panic attacks and limited symptom attacks. ^[14]

Interoceptive

Studies investigating the relationship between interoception and panic disorder have shown that people with panic disorder feel heartbeat sensations more intensely when stimulated by pharmacological agents, suggesting that they experience heightened interoceptive awareness compared to subjects without Parkinson's disease. ^[15]

Causes

Psychological models

While there is not just one explanation for the cause of panic disorder, there are certain perspectives researchers use to explain the disorder. The first one is the biological perspective. Past research concluded that there is irregular norepinephrine activity in people who have panic attacks. ^[16] Current research also supports this perspective as it has been found that those with panic disorder also have a brain circuit that performs improperly. This circuit consists of the amygdala, central gray matter, ventromedial nucleus of the hypothalamus, and the locus ceruleus. ^[17]

There is also a cognitive perspective. Theorists believe that people with panic disorder may experience panic reactions because they mistake their bodily sensations for life-threatening situations. ^[18] These bodily sensations cause some people to feel as though are out of control which may lead to feelings of panic. This misconception of bodily sensations is referred to as anxiety sensitivity, and studies suggest that people who score higher on anxiety sensitivity surveys are five times more likely to be diagnosed with panic disorder. ^[19]

Panic disorder has been found to run in families, which suggests that inheritance plays a strong role in determining who will get it. ^[20]

Psychological factors, stressful life events, life transitions, and environment as well as often thinking in a way that exaggerates relatively normal bodily reactions are also believed to play a role in the onset of panic disorder. Often the first attacks are triggered by physical illnesses, major stress, or certain medications. People who tend to take on excessive responsibilities may develop a tendency to have panic attacks. Individuals with post-traumatic stress disorder (PTSD) also show a much higher rate of panic disorder than the general population. ^[21]

Prepulse inhibition has been found to be reduced in patients with panic disorder. ^[22]

Substance use

Substance use disorders are often correlated with panic attacks. In a study, 39% of people with panic disorder had recreationally used substances. Of those who used alcohol, 63% reported that the alcohol use began prior to the onset of panic, and 59% of those using illicit substances reported that substance use began first. The study that was conducted documented the panic-substance use disorder relationship. Substance use disorder began prior to the onset of panic and substances were used to self-medicate for panic attacks by only a few subjects. ^[23]

In another study, 100 methamphetamine-dependent individuals were analyzed for co-morbid psychiatric disorders; of the 100 individuals, 36% were categorized as having co-morbid psychiatric disorders. Mood and Psychotic disorders were more prevalent than anxiety disorders, which accounted for 7% of the 100 sampled individuals. ^[24]

Smoking

Tobacco smoking increases the risk of developing panic disorder with or without agoraphobia ^{[25] [26]} and panic attacks; smoking started in adolescence or early adulthood particularly increases this risk of developing panic disorder. ^{[27] [28] [29]} While the mechanism of how smoking increases panic attacks is not fully understood, a few hypotheses have been derived. Smoking cigarettes may lead to panic attacks by causing changes in respiratory function (e.g. feeling short of breath). These respiratory changes in turn can lead to the formation of panic attacks, as respiratory symptoms are a prominent feature of panic. ^{[27] [30]} Respiratory abnormalities have been found in children with high levels of anxiety, which suggests that a person with these difficulties may be susceptible to panic attacks, and thus more likely to subsequently develop panic disorder. Nicotine, a stimulant, could contribute to panic attacks. ^{[31] [32]} However, nicotine withdrawal may also cause significant anxiety which could contribute to panic attacks. ^[33]

It is also possible that panic disorder patients smoke cigarettes as a form of self-medication to lessen anxiety. Nicotine and other psychoactive compounds with antidepressant properties in tobacco smoke which act as monoamine oxidase inhibitors in the brain can alter mood and have a calming effect, depending on dose.

Stimulants

A number of clinical studies have shown a positive association between caffeine ingestion and panic disorder and/or anxiogenic effects. ^{[34] [35]} People who have panic disorder are more sensitive to the anxiety-provoking effects of caffeine. One of the major anxiety-provoking effects of caffeine is an increase in heart rate. ^{[36] [37] [38] [39]}

Certain cold and flu medications containing decongestants may also contain pseudoephedrine, ephedrine, phenylephrine, naphazoline and oxymetazoline. These may be avoided by the use of decongestants formulated to prevent causing high blood pressure. ^[40]

Alcohol and sedatives

About 30% of people with panic disorder use alcohol and 17% use other psychoactive drugs. ^[41] This is in comparison with 61% (alcohol) ^[42] and 7.9% (other psychoactive drugs) ^[43] of the general population who use alcohol and psychoactive drugs, respectively. Utilization of recreational drugs or alcohol generally make symptoms worse. ^[44] Most stimulant drugs (caffeine, nicotine, cocaine) would be expected to worsen the condition, since they directly increase the symptoms of panic, such as heart rate.

Deacon and Valentiner (2000) ^[45] conducted a study that examined co-morbid panic attacks and substance use in a non-clinical sample of young adults who experienced regular panic attacks. The authors found that compared to healthy controls, sedative use was greater for non-clinical participants who experienced panic attacks. These findings are consistent with the suggestion made by Cox, Norton, Dorward, and Fergusson (1989) ^[46] that panic disorder patients self-medicate if they believe that certain substances will be successful in alleviating their symptoms. If panic disorder patients are indeed self-medicating, there may be a portion of the population with undiagnosed panic disorder who will not seek professional help as a result of their own self-medication. In fact, for some patients panic disorder is only diagnosed after they seek treatment for their self-medication habit. ^[47]

While alcohol initially helps ease panic disorder symptoms, medium- or long-term hazardous alcohol use can cause panic disorder to develop or worsen during alcohol intoxication, especially during alcohol withdrawal syndrome. ^[48] This effect is not unique to alcohol but can also occur with long-term use of drugs which have a similar mechanism of action to alcohol such as the benzodiazepines which are sometimes prescribed as tranquilizers to people with alcohol problems. ^[48] The reason chronic alcohol misuse worsens panic disorder is due to distortion of the brain chemistry and function. ^{[49] [50] [51]}

Approximately 10% of patients will experience notable protracted withdrawal symptoms, which can include panic disorder, after discontinuation of benzodiazepines. Protracted withdrawal symptoms tend to resemble those seen during the first couple of months of withdrawal but usually are of a subacute level of severity compared to the symptoms seen during the first 2 or 3 months of withdrawal. It is not known definitively whether such symptoms persisting long after withdrawal are related to true pharmacological withdrawal or whether they are due to structural neuronal damage as a result of chronic use of benzodiazepines or withdrawal. Nevertheless, such symptoms do typically lessen as the months and years go by eventually disappearing altogether. ^[52]

A significant proportion of patients attending mental health services for conditions including anxiety disorders such as panic disorder or social phobia have developed these conditions as a result of recreational alcohol or sedative use. Anxiety may pre-exist alcohol or sedative dependence, which then acts to perpetuate or worsen the underlying anxiety disorder. Someone experiencing the toxic effects of recreational alcohol use or chronic sedative use will not benefit from other therapies or medications for underlying psychiatric conditions as they do not address the root cause of the symptoms. Recovery from sedative symptoms may temporarily worsen during alcohol withdrawal or benzodiazepine withdrawal. ^{[53] [54] [55] [56]}

Genetic Hypotheses

Genetic vulnerability to panic disorder remains a gray area. However, some researchers have found strong causative links. In general, neurochemical dysfunction plays the most prominent role in genetic cause for panic disorder. This can be seen in factors such as autonomic imbalances, decreased GABA-ergic tone, increased adenosine receptor function, increased cortisol levels, and disturbances in other hormones and/or neurotransmitters (e.g., norepinephrine). Some studies have looked at theories suggesting a chronic state of hyperventilation and other carbon dioxide receptor hypersensitivity could represent genetic causes for panic disorder. ^[57] Differing proposed causes look at chromosomal regions 13q, 14q, 22q, and 4q31-q34 as possible associations to heritability. ^[58]

Mechanism

The neuroanatomy of panic disorder largely overlaps with that of most anxiety disorders. Neuropsychological, neurosurgical, and neuroimaging studies implicate the insula, amygdala, hippocampus, anterior cingulate cortex (ACC), lateral prefrontal cortex, and periaqueductal grey. During acute panic attacks, viewing emotionally charged words, and rest, most studies find elevated blood flow or metabolism. However, the observation of amygdala hyperactivity is not entirely consistent, especially in studies that evoke panic attacks chemically. Hippocampus hyperactivity has been observed during rest and viewing emotionally charged pictures, which has been hypothesized to be related to memory retrieval bias towards anxious memories. Insula hyperactivity during the onset of and over the course of acute panic episodes is thought to be related to abnormal introceptive processes; the perception that bodily sensations are "wrong" is a transdiagnostic finding (i.e. found across multiple anxiety disorders), and may be related to insula dysfunction. Rodent and human studies heavily implicate the periaqueductal grey in generating fear responses, and abnormalities related to the structure and metabolism in the PAG have been reported in panic disorder. The frontal cortex is implicated in panic disorder by multiple lines of evidence. Damage to the dorsal ACC has been reported to lead to panic disorder. Elevated ventral ACC and dorsolateral prefrontal cortex during symptom provocation and viewing emotional stimuli have also been reported, although findings are not consistent. ^[59]

Researchers studying some individuals with panic disorder propose they may have a chemical imbalance within the limbic system and one of its regulatory chemicals GABA-A. The reduced production of GABA-A sends false information to the amygdala which regulates the body's "fight or flight" response mechanism and, in return, produces the physiological symptoms that lead to the disorder. Clonazepam, an anticonvulsant benzodiazepine with a long half-life, has been successful in keeping the condition under control. ^[60]

Recently, researchers have begun to identify mediators and moderators of aspects of panic disorder. One such mediator is the partial pressure of carbon dioxide, which mediates the relationship between panic disorder patients receiving breathing training and anxiety sensitivity; thus, breathing training affects the partial pressure of carbon dioxide in a patient's arterial blood, which in turn lowers anxiety sensitivity. ^[61] Another mediator is hypochondriacal concerns, which mediate the relationship between anxiety sensitivity and panic symptomatology; thus, anxiety sensitivity affects hypochondriacal concerns which, in turn, affect panic symptomatology. ^[62]

Perceived threat control has been identified as a moderator within panic disorder, moderating the relationship between anxiety sensitivity and agoraphobia; thus, the level of perceived threat control dictates the degree to which anxiety sensitivity results in agoraphobia. ^[63] Another recently identified moderator of panic disorder is genetic variations in the gene coding for galanin; these genetic variations moderate the relationship between females with panic disorder and the level of severity of panic disorder symptomatology. ^[64]

Diagnosis

The DSM-IV-TR diagnostic criteria for panic disorder require unexpected, recurrent panic attacks, followed in at least one instance by at least a month of a significant and related behavior change, a persistent concern of more attacks, or a worry about the attack's consequences. There are two types, one with and one without agoraphobia. Diagnosis is excluded by attacks due to a drug or medical condition, or by panic attacks that are better accounted for by other mental disorders. ^[65]
The ICD-10 diagnostic criteria:
The essential feature is recurrent attacks of severe anxiety (panic), which are not restricted to any particular situation or set of circumstances and are therefore unpredictable.
The dominant symptoms include:

• sudden onset of palpitations
• chest pain or tightness
• shortness of breath or hyperventilation
• choking sensations
• dizziness
• feelings of unreality (depersonalization or derealization)
• secondary fear of dying, losing control, or going mad

Panic disorder should not be given as the main diagnosis if the person has a depressive disorder at the time the attacks start; in these circumstances, the panic attacks are probably secondary to depression. ^[66]

The Panic Disorder Severity Scale (PDSS) is a questionnaire for measuring the severity of panic disorder. ^[67]

Treatment

Panic disorder is a serious health problem that in many cases can be successfully treated, although there is no known cure. Identification of treatments that engender as full a response as possible, and can minimize relapse, is imperative. ^[68] Cognitive behavioral therapy and positive self-talk specific for panic ^[69] are the treatments of choice for panic disorder. Several studies show that 85 to 90 percent of panic disorder patients treated with CBT recover completely from their panic attacks within 12 weeks. ^[70] When cognitive behavioral therapy is not an option, pharmacotherapy can be used. SSRIs are considered a first-line pharmacotherapeutic option. ^{[71] [72] [73]}

Psychotherapy

Panic disorder is not the same as phobic symptoms, although many phobias commonly result from panic disorder. ^[74] CBT and one tested form of psychodynamic psychotherapy have been shown efficacious in treating panic disorder with and without agoraphobia. ^{[75] [76] [77]} A number of randomized clinical trials have shown that CBT achieves reported panic-free status in 70–90% of patients about 2 years after treatment. ^[70]

A 2009 Cochrane review found little evidence concerning the efficacy of psychotherapy in combination with benzodiazepines such that recommendations could not be made. ^[78]

Symptom inductions generally occur for one minute and may include:

• Intentional hyperventilation – creates lightheadedness, derealization, blurred vision, dizziness
• Spinning in a chair – creates dizziness, disorientation
• Straw breathing – creates dyspnea, airway constriction
• Breath holding – creates sensation of being out of breath
• Running in place – creates increased heart rate, respiration, perspiration
• Body tensing – creates feelings of being tense and vigilant

Another form of psychotherapy that has shown effectiveness in controlled clinical trials is panic-focused psychodynamic psychotherapy, which focuses on the role of dependency, separation anxiety, and anger in causing panic disorder. The underlying theory posits that due to biochemical vulnerability, traumatic early experiences, or both, people with panic disorder have a fearful dependence on others for their sense of security, which leads to separation anxiety and defensive anger. Therapy involves first exploring the stressors that lead to panic episodes, then probing the psychodynamics of the conflicts underlying panic disorder and the defense mechanisms that contribute to the attacks, with attention to transference and separation anxiety issues implicated in the therapist-patient relationship. ^[79]

Comparative clinical studies suggest that muscle relaxation techniques and breathing exercises are not efficacious in reducing panic attacks. In fact, breathing exercises may actually increase the risk of relapse. ^[80]

Appropriate treatment by an experienced professional can prevent panic attacks or at least substantially reduce their severity and frequency—bringing significant relief to 70 to 90 percent of people with panic disorder. ^[81] Relapses may occur, but they can often be effectively treated just like the initial episode.

vanApeldoorn, F.J. et al. (2011) demonstrated the additive value of a combined treatment incorporating an SSRI treatment intervention with cognitive behavior therapy (CBT). ^[82] Gloster et al. (2011) went on to examine the role of the therapist in CBT. They randomized patients into two groups: one being treated with CBT in a therapist guided environment, and the second receiving CBT through instruction only, with no therapist guided sessions. The findings indicated that the first group had a somewhat better response rate, but that both groups demonstrated a significant improvement in reduction of panic symptomatology. These findings lend credibility to the application of CBT programs to patients who are unable to access therapeutic services due to financial, or geographic inaccessibility. ^[83] Koszycky et al. (2011) discuss the efficacy of self-administered cognitive behavioural therapy (SCBT) in situations where patients are unable to retain the services of a therapist. Their study demonstrates that it is possible for SCBT in combination with an SSRI to be as effective as therapist-guided CBT with SSRI. Each of these studies contributes to a new avenue of research that allows effective treatment interventions to be made more easily accessible to the population. ^[84]

Cognitive behavioral therapy

Cognitive behavioral therapy encourages patients to confront the triggers that induce their anxiety. By facing the very cause of the anxiety, it is thought to help diminish the irrational fears that are causing the issues to begin with. The therapy begins with calming breathing exercises, followed by noting the changes in physical sensations felt as soon as anxiety begins to enter the body. Many clients are encouraged to keep journals. In other cases, therapists may try and induce feelings of anxiety so that the root of the fear can be identified. ^[85]

Comorbid clinical depression, personality disorders and alcohol abuse are known risk factors for treatment failure. ^[86]

As with many disorders, having a support structure of family and friends who understand the condition can help increase the rate of recovery. During an attack, it is not uncommon for the affected to develop irrational, immediate fear, which can often be dispelled by a supporter who is familiar with the condition. For more serious or active treatment, there are support groups for those with anxiety which can help people understand and deal with the disorder.

Current treatment guidelines American Psychiatric Association and the American Medical Association primarily recommend either cognitive-behavioral therapy or one of a variety of psychopharmacological interventions. Some evidence exists supporting the superiority of combined treatment approaches. ^{[75] [87] [88]}

Another option is self-help based on principles of cognitive-behavioral therapy. ^[89] Using a book or a website, a person does the kinds of exercises that would be used in therapy, but they do it on their own, perhaps with some email or phone support from a therapist. ^[89] A systematic analysis of trials testing this kind of self-help found that websites, books, and other materials based on cognitive-behavioral therapy could help some people. ^[89] The best-studied conditions are panic disorder and social phobia. ^[89]

Interoceptive techniques

Interoceptive exposure is sometimes used for panic disorder. People's interoceptive triggers of anxiety are evaluated one-by-one before conducting interoceptive exposures, such as addressing palpitation sensitivity via light exercise. ^[15] Despite evidence of its clinical efficacy, this practice is reportedly used by only 12–20% of psychotherapists. Potential reasons for this underutilization include "lack of training sites, logistical hurdles (e.g., occasional need for exposure durations longer than a standard therapy session), policies against conducting exposures outside of the workplace setting, and perhaps most tellingly, negative therapist beliefs (e.g., that interoceptive exposures are unethical, intolerable, or even harmful)." ^[15]

Medication

Appropriate medications are effective for panic disorder. Selective serotonin reuptake inhibitors are first line treatments rather than benzodiazapines due to concerns with the latter regarding tolerance, dependence and abuse. ^[90] Although there is little evidence that pharmacological interventions can directly alter phobias, few studies have been performed, and medication treatment of panic makes phobia treatment far easier (an example in Europe where only 8% of patients receive appropriate treatment). ^[91]

Medications can include:

• Antidepressants (SSRIs, MAOIs, tricyclic antidepressants and norepinephrine reuptake inhibitors): The most common SSRIs used while treating panic disorder include Prozac, Luvox, Zoloft, and Paxil. These have been reported as the most effective in preventing panic attacks. ^[92] The most researched and support tricyclic antidepressants are Tofranil and Anafranil. ^[92] Other tricyclic antidepressants used for treatment include Pamelor, Norpramin, and Elavil. While these are potentially helpful in treating panic disorder, research has not been as conclusive when compared to the two previously mentioned medications. Monoamine oxidase inhibitors (MAOIs) can be used as a second-line or third-line treatment, but have shown limited efficacy in the treatment of panic disorder, and also carry significant risks of adverse effects and medication interactions. ^[93]
• Antianxiety agents (benzodiazepines): The American Psychiatric Association states that benzodiazepines can be effective for the treatment of panic disorder and recommends that the choice of whether to use benzodiazepines, antidepressants with anti-panic properties or psychotherapy should be based on the individual patient's history and characteristics. ^[94] Other experts believe that benzodiazepines are best avoided due to the risks of the development of tolerance and physical dependence. ^[95] The World Federation of Societies of Biological Psychiatry, say that benzodiazepines should not be used as a first-line treatment option but are an option for treatment-resistant cases of panic disorder. ^[96] Despite increasing focus on the use of antidepressants and other agents for the treatment of anxiety as recommended best practice, benzodiazepines have remained a commonly used medication for panic disorder. ^{[97] [98]} They reported that in their view there is insufficient evidence to recommend one treatment over another for panic disorder. The APA noted that while benzodiazepines have the advantage of a rapid onset of action, that this is offset by the risk of developing a benzodiazepine dependence. ^[99] The National Institute for Clinical Excellence came to a different conclusion, they pointed out the problems of using uncontrolled clinical trials to assess the effectiveness of pharmacotherapy and based on placebo-controlled research they concluded that benzodiazepines were not effective in the long-term for panic disorder and recommended that benzodiazepines not be used for longer than 4 weeks for panic disorder. Instead NICE clinical guidelines recommend alternative pharmacotherapeutic or psychotherapeutic interventions. ^[100] When compared to placebos, benzodiazepines demonstrate possible superiority in the short term but the evidence is low quality with limited applicability to clinical practice. ^[101]

Other treatments

For some people, anxiety can be greatly reduced by discontinuing the use of caffeine. ^[102] Anxiety can temporarily increase during caffeine withdrawal. ^{[103] [104] [105]}

Epidemiology

Age-standardized disability-adjusted life year rates for panic disorder per 100,000 inhabitants in 2004:

  no data

  less than 95

  95–96.5

  96.5–98

  98–99.5

  99.5–101

  101–102.5

  102.5–104

  104–105.5

  105.5–107

  107–108.5

  108.5–110

  more than 110

Panic disorder typically begins during early adulthood; roughly half of all people who have panic disorder develop the condition between the ages of 17 and 24, especially those subjected to traumatic experiences. However, some studies suggest that the majority of young people affected for the first time are between the ages of 25 and 30. Women are twice as likely as men to develop panic disorder ^[106] and it occurs far more frequently in people of above average intelligence.

Panic disorder can continue for months or years, depending on how and when treatment is sought. If left untreated, it may worsen to the point where one's life is seriously affected by panic attacks and by attempts to avoid or conceal the condition. In fact, many people have had problems with personal relationships, education and employment while struggling to cope with panic disorder. Some people with panic disorder may conceal their condition because of the stigma of mental illness. In some individuals, symptoms may occur frequently for a period of months or years, then many years may pass with little or no symptoms. In some cases, the symptoms persist at the same level indefinitely. There is also some evidence that many individuals (especially those who develop symptoms at an early age) may experience a complete cessation of symptoms later in life (e.g., over age 50). ^[107]

In 2000, the World Health Organization found prevalence and incidence rates for panic disorder to be very similar across the globe. Age-standardized prevalence per 100,000 ranged from 309 in Africa to 330 in East Asia for men and from 613 in Africa to 649 in North America, Oceania, and Europe for women. ^[108]

Children

A retrospective study has shown that 40% of adult panic disorder patients reported that their disorder began before the age of 20. ^[109] In an article examining the phenomenon of panic disorder in youth, Diler et al. (2004) ^[110] found that only a few past studies have examined the occurrence of juvenile panic disorder. They report that these studies have found that the symptoms of juvenile panic disorder almost replicate those found in adults (e.g. heart palpitations, sweating, trembling, hot flashes, nausea, abdominal distress, and chills). ^{[111] [112] [113] [114] [115]} The anxiety disorders co-exist with staggeringly high numbers of other mental disorders in adults. ^[116] The same comorbid disorders that are seen in adults are also reported in children with juvenile panic disorder. Last and Strauss (1989) ^[117] examined a sample of 17 adolescents with panic disorder and found high rates of comorbid anxiety disorders, major depressive disorder, and conduct disorders. Eassau et al. (1999) ^[113] also found a high number of comorbid disorders in a community-based sample of adolescents with panic attacks or juvenile panic disorder. Within the sample, adolescents were found to have the following comorbid disorders: major depressive disorder (80%), dysthymic disorder (40%), generalized anxiety disorder (40%), somatoform disorders (40%), substance abuse (40%), and specific phobia (20%). Consistent with this previous work, Diler et al. (2004) found similar results in their study in which 42 youths with juvenile panic disorder were examined. Compared to non-panic anxiety disordered youths, children with panic disorder had higher rates of comorbid major depressive disorder and bipolar disorder.

Children differ from adolescents and adults in their interpretation and ability to express their experience. Like adults, children experience physical symptoms including accelerated heart rate, sweating, trembling or shaking, shortness of breath, nausea or abdominal pain, dizziness or light-headedness. In addition, children also experience cognitive symptoms like fear of dying, feelings of being detached from oneself and feelings of losing control or going crazy. Children are often unable to articulate these higher-order manifestations of fear; they simply feel that something is wrong and that they are very afraid. Children can only describe physical symptoms. They have not yet developed the ability to put these symptoms together and label them as fear. Parents often feel helpless when they watch their child suffer. They can help children give a name to their experience, and empower them to overcome the fear they are experiencing ^[118]

The role of the parent in treatment and intervention for children diagnosed with panic disorder is discussed by McKay & Starch (2011). They point out that there are several levels at which parental involvement should be considered. The first involves the initial assessment. Parents, as well as the child, should be screened for attitudes and treatment goals, as well as for levels of anxiety or conflict in the home. The second involves the treatment process in which the therapist should meet with the family as a unit as frequently as possible. Ideally, all family members should be aware and trained in the process of cognitive behavior therapy (CBT) in order to encourage the child to rationalize and face fears rather than employ avoidant safety behaviors. McKay & Storch (2011) suggest training/modeling of therapeutic techniques and in-session involvement of the parents in the treatment of children to enhance treatment efficacy. ^[119]

Despite the evidence pointing to the existence of early-onset panic disorder, the DSM-IV-TR currently only recognizes six anxiety disorders in children: separation anxiety disorder, generalized anxiety disorder, specific phobia, obsessive-compulsive disorder, social anxiety disorder (a.k.a. social phobia), and post-traumatic stress disorder. Panic disorder is notably excluded from this list.

References

1. "Anxiety Disorders". Mental Health Information: Health Topics. National Institute of Mental Health. March 2016. Archived from the original on 29 September 2016. Retrieved 1 October 2016.
2. American Psychiatric Association (2013), Diagnostic and Statistical Manual of Mental Disorders (5th ed.), Arlington: American Psychiatric Publishing, pp.  208–217, 938, ISBN   978-0-89042-555-8
3. "Panic Disorder: When Fear Overwhelms". National Institute of Mental Health. 2013. Archived from the original on 4 October 2016. Retrieved 1 October 2016.
4. Craske MG, Stein MB (December 2016). "Anxiety". Lancet. 388 (10063): 3048–3059. doi:10.1016/S0140-6736(16)30381-6. PMID   27349358. S2CID   208789585.
5. "F41.0 Panic disorder [episodic paroxysmal anxiety]". The ICD-10 Classification of Mental and Behavioural Disorders Clinical descriptions and diagnostic guidelines. World Health Organization. 2004 [1992]. p. 139. ISBN   92-4-154422-8.
6. Herr NR, Williams JW, Benjamin S, McDuffie J (July 2014). "Does this patient have generalized anxiety or panic disorder?: The Rational Clinical Examination systematic review". JAMA. 312 (1): 78–84. doi:10.1001/jama.2014.5950. PMID   25058220.
7. "Panic disorder". UK National Heath Service. 16 February 2021.
8. Craske, Michelle G.; Kircanski, Katharina; Epstein, Alyssa; Wittchen, Hans-Ulrich; Pine, Danny S.; Lewis-Fernández, Roberto; Hinton, Devon (February 2010). "Panic disorder: a review of DSM-IV panic disorder and proposals for DSM-V". Depression and Anxiety. 27 (2): 93–112. doi: 10.1002/da.20654 . PMID   20099270. S2CID   17789728.
9. Freire, Rafael C.; Perna, Giampaolo; Nardi, Antonio E. (July 2010). "Panic Disorder Respiratory Subtype: Psychopathology, Laboratory Challenge Tests, and Response to Treatment". Harvard Review of Psychiatry. 18 (4): 220–229. doi:10.3109/10673229.2010.493744. PMID   20597592. S2CID   13567414.
10. Diler, Rasim Somer; Birmaher, Boris; Brent, David A.; Axelson, David A.; Firinciogullari, Sekip; Chiapetta, Laurel; Bridge, Jeff (2004). "Phenomenology of panic disorder in youth". Depression and Anxiety. 20 (1): 39–43. doi: 10.1002/da.20018 . PMID   15368595. S2CID   23612310.
11. Frisch, N.; Frisch, L. (2006). Psychiatric Mental Health Nursing (3rd ed.). Canada: Thomson Delmar Learning. ISBN   978-1-4018-5644-1.^{[ page needed ]}
12. Healy (2009) Psychiatric Drugs Explained
13. O'Mahony, J.F; Ward, B.G (2003). "Differences between those who panic by day and those who also panic by night". Journal of Behavior Therapy and Experimental Psychiatry. 34 (3–4): 239–249. doi:10.1016/j.jbtep.2003.10.001. PMID   14972671.
14. "Anxiety". Parkinson's Foundation.
15. Khalsa, Sahib S.; Lapidus, Rachel C. (2016). "Can Interoception Improve the Pragmatic Search for Biomarkers in Psychiatry?". Frontiers in Psychiatry. 7: 121. doi: 10.3389/fpsyt.2016.00121 . PMC   4958623 . PMID   27504098.
16. Comer, Ronald (2014). Fundamentals of Abnormal Psychology (7th ed.). New York: Worth Publishers. p. 122. ISBN   978-1-4292-9563-5.
17. Etkin A (2010). "Functional neuroanatomy of anxiety: a neural circuit perspective". In Stein MB, Steckler T (eds.). Behavioral Neurobiology of Anxiety and Its Treatment. Current Topics in Behavioral Neurosciences. Vol. 2. pp. 251–77. doi:10.1007/7854_2009_5. ISBN   978-3-642-02911-0. PMID   21309113.
18. Clark, D.A.; Beck, A.T. (2011). The Anxiety and Worry Workbook: The Cognitive Behavioral Solution. Guilford Press. ISBN   978-1-60623-918-6.
19. Hawks E, Blumenthal H, Feldner MT, Leen-Feldner EW, Jones R (September 2011). "An examination of the relation between traumatic event exposure and panic-relevant biological challenge responding among adolescents". Behavior Therapy. 42 (3). Elsevier Ltd: 427–38. doi:10.1016/j.beth.2010.11.002. PMID   21658525.
20. "Panic Disorder and Pharmacological Treatment Options". Archived from the original on 15 April 2012. Retrieved 12 May 2012.
21. Flory, J. D.; Yehuda, R. (2015). "Comorbidity between post-traumatic stress disorder and major depressive disorder: alternative explanations and treatment considerations". Dialogues in Clinical Neuroscience. 17 (2): 141–150. doi:10.31887/DCNS.2015.17.2/jflory. PMC   4518698 . PMID   26246789.
22. Ludewig S, Geyer MA, Ramseier M, Vollenweider FX, Rechsteiner E, Cattapan-Ludewig K (January 2005). "Information-processing deficits and cognitive dysfunction in panic disorder". Journal of Psychiatry & Neuroscience. 30 (1): 37–43. PMC   543839 . PMID   15644996.
23. Katerndahl DA, Realini JP (1999). "Relationship between substance abuse and panic attacks". Addictive Behaviors. 24 (5): 731–6. doi:10.1016/s0306-4603(98)00078-1. PMID   10574314.
24. Akindipe T, Wilson D, Stein DJ (June 2014). "Psychiatric disorders in individuals with methamphetamine dependence: prevalence and risk factors". Metabolic Brain Disease. 29 (2): 351–7. doi:10.1007/s11011-014-9496-5. PMID   24532047. S2CID   14880172.
25. Roy-Byrne PP, Craske MG, Stein MB (September 2006). "Panic disorder". Lancet. 368 (9540): 1023–32. doi:10.1016/S0140-6736(06)69418-X. PMID   16980119. S2CID   43357552.
26. Cosci F, Knuts IJ, Abrams K, Griez EJ, Schruers KR (May 2010). "Cigarette smoking and panic: a critical review of the literature". The Journal of Clinical Psychiatry. 71 (5): 606–15. doi:10.4088/JCP.08r04523blu. PMID   19961810.
27. Johnson JG, Cohen P, Pine DS, Klein DF, Kasen S, Brook JS (November 2000). "Association between cigarette smoking and anxiety disorders during adolescence and early adulthood". JAMA. 284 (18): 2348–51. doi:10.1001/jama.284.18.2348. PMID   11066185.
28. Isensee B, Wittchen HU, Stein MB, Höfler M, Lieb R (July 2003). "Smoking increases the risk of panic: findings from a prospective community study". Archives of General Psychiatry. 60 (7): 692–700. doi:10.1001/archpsyc.60.7.692. PMID   12860773.
29. Goodwin RD, Lewinsohn PM, Seeley JR (November 2005). "Cigarette smoking and panic attacks among young adults in the community: the role of parental smoking and anxiety disorders". Biological Psychiatry. 58 (9): 686–93. doi:10.1016/j.biopsych.2005.04.042. PMID   16018987. S2CID   33807953.
30. Breslau N, Klein DF (December 1999). "Smoking and panic attacks: an epidemiologic investigation". Archives of General Psychiatry. 56 (12): 1141–7. doi:10.1001/archpsyc.56.12.1141. PMID   10591292.
31. Pine DS, Klein RG, Coplan JD, Papp LA, Hoven CW, Martinez J, et al. (October 2000). "Differential carbon dioxide sensitivity in childhood anxiety disorders and nonill comparison group". Archives of General Psychiatry. 57 (10): 960–7. doi:10.1001/archpsyc.57.10.960. PMID   11015814.
32. Gorman JM, Kent J, Martinez J, Browne S, Coplan J, Papp LA (February 2001). "Physiological changes during carbon dioxide inhalation in patients with panic disorder, major depression, and premenstrual dysphoric disorder: evidence for a central fear mechanism". Archives of General Psychiatry. 58 (2): 125–31. doi:10.1001/archpsyc.58.2.125. PMID   11177114.
33. Leyro TM, Zvolensky MJ (March 2013). "The Interaction of Nicotine Withdrawal and Panic Disorder in the Prediction of Panic-relevant Responding to a Biological Challenge". Psychology of Addictive Behaviors. 27 (1): 90–101. doi:10.1037/a0029423. PMC   3663295 . PMID   22867297.
34. Hughes RN (June 1996). "Drugs which Induce Anxiety: Caffeine" (PDF). New Zealand Journal of Psychology. 25 (1): 36–42. Archived from the original (PDF) on 25 January 2016.
35. Vilarim MM, Rocha Araujo DM, Nardi AE (August 2011). "Caffeine challenge test and panic disorder: a systematic literature review". Expert Review of Neurotherapeutics. 11 (8): 1185–95. doi:10.1586/ern.11.83. PMID   21797659. S2CID   5364016.
36. Halter MJ (2008). Varcarolis' Foundations of Psychiatric Mental Health Nursing: A Clinical Approach. Elsevier Health Sciences. ISBN   978-1-4557-5358-1.
37. Lara DR (2010). "Caffeine, mental health, and psychiatric disorders". Journal of Alzheimer's Disease. 20 (Suppl 1): S239-48. doi: 10.3233/JAD-2010-1378 . PMID   20164571.
38. Lee MA, Flegel P, Greden JF, Cameron OG (May 1988). "Anxiogenic effects of caffeine on panic and depressed patients". The American Journal of Psychiatry. 145 (5): 632–5. doi:10.1176/ajp.145.5.632. PMID   3358468.
39. Nardi AE, Lopes FL, Valença AM, Freire RC, Veras AB, de-Melo-Neto VL, et al. (May–June 2007). "Caffeine challenge test in panic disorder and depression with panic attacks". Comprehensive Psychiatry. 48 (3): 257–63. doi:10.1016/j.comppsych.2006.12.001. PMID   17445520.
40. "High blood pressure and cold remedies: Which are safe?". Mayo Clinic . Archived from the original on 31 January 2017. Retrieved 21 January 2017.
41. "Panic Disorder". Mental Health America. Archived from the original on 6 February 2014. Retrieved 2 July 2007.
42. "FASTSTATS — Alcohol Use". Centers for Disease Control and Prevention. Archived from the original on 8 July 2013. Retrieved 28 June 2013.
43. "FASTSTATS — Illegal Drug Use". Centers for Disease Control and Prevention. 30 May 2013. Archived from the original on 5 July 2013. Retrieved 28 June 2013.
44. Practice guideline for the treatment of patients with panic disorder (PDF). American Psychiatric Association. 2010. p. 41. Despite the anxiolytic effects perceived by some patients, use of many substances can trigger or worsen panic symptoms.
45. Deacon BJ, Valentiner DP (2000). "Substance use and non-clinical panic attacks in a young adult sample". Journal of Substance Abuse. 11 (1): 7–15. doi:10.1016/S0899-3289(99)00017-6. PMID   10756510.
46. Cox BJ, Norton GR, Dorward J, Fergusson PA (1989). "The relationship between panic attacks and chemical dependencies". Addictive Behaviors. 14 (1): 53–60. doi:10.1016/0306-4603(89)90016-6. PMID   2718824.
47. Cox BJ, Norton GR, Swinson RP, Endler NS (1990). "Substance abuse and panic-related anxiety: a critical review". Behaviour Research and Therapy. 28 (5): 385–93. doi:10.1016/0005-7967(90)90157-E. PMID   2256896.
48. Terra MB, Figueira I, Barros HM (August 2004). "Impact of alcohol intoxication and withdrawal syndrome on social phobia and panic disorder in alcoholic inpatients". Revista do Hospital das Clinicas. 59 (4): 187–92. doi: 10.1590/S0041-87812004000400006 . PMID   15361983.
49. Wetterling T, Junghanns K (December 2000). "Psychopathology of alcoholics during withdrawal and early abstinence". European Psychiatry. 15 (8): 483–8. doi:10.1016/S0924-9338(00)00519-8. PMID   11175926. S2CID   24094651.
50. Cowley DS (January 1992). "Alcohol abuse, substance abuse, and panic disorder". The American Journal of Medicine. 92 (1A): 41S–48S. doi:10.1016/0002-9343(92)90136-Y. PMID   1346485.
51. Cosci F, Schruers KR, Abrams K, Griez EJ (June 2007). "Alcohol use disorders and panic disorder: a review of the evidence of a direct relationship". The Journal of Clinical Psychiatry. 68 (6): 874–80. doi:10.4088/JCP.v68n0608. PMID   17592911.
52. Ashton H (1991). "Protracted withdrawal syndromes from benzodiazepines". Journal of Substance Abuse Treatment. 8 (1–2): 19–28. doi:10.1016/0740-5472(91)90023-4. PMID   1675688.
53. Cohen SI (February 1995). "Alcohol and benzodiazepines generate anxiety, panic and phobias". Journal of the Royal Society of Medicine. 88 (2): 73–7. PMC   1295099 . PMID   7769598.
54. Belleville G, Morin CM (March 2008). "Hypnotic discontinuation in chronic insomnia: impact of psychological distress, readiness to change, and self-efficacy". Health Psychology. 27 (2): 239–48. doi:10.1037/0278-6133.27.2.239. PMID   18377143.
55. Ashton CH (1987). "Benzodiazepine Withdrawal: Outcome in 50 Patients". British Journal of Addiction. 82 (6): 655–671. doi:10.1111/j.1360-0443.1987.tb01529.x. PMID   2886145.
56. Onyett SR (April 1989). "The benzodiazepine withdrawal syndrome and its management". The Journal of the Royal College of General Practitioners. 39 (321): 160–3. PMC   1711840 . PMID   2576073.
57. Memon, Mohammed A; Welton, Randon S; Brenner, Berry E; Daniels, Colin Y; Harwood, Robert; Keim, Samuel M; Plewa, Michael C; Talavera, Francisco; Yerkes, Sandra. "Panic Disorder". Medscape. Retrieved 6 February 2023.
58. Bhatt, Nita V; Baker, Matthew J; Jain, Vina B; Bienenfeld, David; Yates, William R; Bessman, Edward; Brenner, Berry E; Daniels, Colin Y; Erikson, Marilyn T; Friedman, Sandra L; Harwood, Robert; Keim, Samuel M; Plewa, Michael C; Talavera, Francisco; Tefera, Lemeneh; Tomao, Lauren Claire. "Anxiety Disorders". Medscape. Retrieved 6 February 2023.
59. Goodkind, Madeleine S.; Etkin, Amit (2017). "Functional Neurocircuitry and Neuroimaging Studies of Anxiety Disorders". In Charney, Dennis S; Nestler, Eric J; Sklar, Pamela; Buxbaum, Joseph D (eds.). Charney & Nestler's Neurobiology of Mental Illness. pp. 435–450. doi:10.1093/med/9780190681425.003.0034. ISBN   978-0-19-068142-5.
60. Cameron, Oliver G.; Huang, Grace C.; Nichols, Thomas; Koeppe, Robert A.; Minoshima, Satoshi; Rose, David; Frey, Kirk A. (1 July 2007). "Reduced γ-Aminobutyric AcidA–Benzodiazepine Binding Sites in Insular Cortex of Individuals With Panic Disorder". Archives of General Psychiatry. 64 (7): 793–800. doi:10.1001/archpsyc.64.7.793. PMID   17606813.
61. Meuret AE, Rosenfield D, Hofmann SG, Suvak MK, Roth WT (March 2009). "Changes in respiration mediate changes in fear of bodily sensations in panic disorder". Journal of Psychiatric Research. 43 (6): 634–41. doi:10.1016/j.jpsychires.2008.08.003. PMC   3327292 . PMID   18835608.
62. Berrocal C, Moreno FR, Cano J (May 2007). "Anxiety sensitivity and panic symptomatology: the mediator role of hypochondriacal concerns". The Spanish Journal of Psychology. 10 (1): 159–66. doi:10.1017/s1138741600006429. PMID   17549889. S2CID   2605017.
63. White KS, Brown TA, Somers TJ, Barlow DH (January 2006). "Avoidance behavior in panic disorder: the moderating influence of perceived control". Behaviour Research and Therapy. 44 (1): 147–57. doi:10.1016/j.brat.2005.07.009. PMID   16300725.
64. Unschuld PG, Ising M, Erhardt A, Lucae S, Kohli M, Kloiber S, et al. (January 2008). "Polymorphisms in the galanin gene are associated with symptom-severity in female patients suffering from panic disorder". Journal of Affective Disorders. 105 (1–3): 177–84. doi:10.1016/j.jad.2007.05.006. PMID   17573119.
65. American Psychiatric Association (2000). "Panic Disorder without Agoraphobia". Diagnostic and Statistical Manual of Mental Disorders (4th, text revision (DSM-IV-TR) ed.). ISBN   0-89042-025-4.
66. "F41.0 Panic disorder [episodic paroxysmal anxiety]". ICD-10 Version:2019. World Health Organization.
67. Shear, M. Katherine; Clark, Duncan; Feske, and Ulrika (1 February 1998). "The Road to Recovery in Panic Disorder: Response, Remission, and Relapse" . The Journal of Clinical Psychiatry. 59 (suppl 8): 4–8. PMID   9707156.
68. Salvador-Carulla L, Seguí J, Fernández-Cano P, Canet J (April 1995). "Costs and offset effect in panic disorders". The British Journal of Psychiatry. Supplement. 166 (27): 23–8. doi:10.1192/S0007125000293367. PMID   7794590. S2CID   10731758.
69. Ellis R, Ryan JA (2005). "Emotional Intelligence and Positive Psychology: Therapist Tools for Training/Coaching Clients to Move Beyond Emotional Relief". Annals of the American Psychotherapy Association. 8 (3): 42–43.
70. Nolen-Hoeksema S (2013). Abnormal Psychology. McGraw-Hill. p. 132. ISBN   978-0-07-803538-8.
71. Cloos JM (January 2005). "The treatment of panic disorder". Current Opinion in Psychiatry. 18 (1): 45–50. PMID   16639183. Archived from the original on 4 April 2011.
72. Foldes-Busque G, Marchand A, Landry P (October 2007). "[Early detection and treatment of panic disorder with or without agoraphobia: update]". Canadian Family Physician. 53 (10): 1686–93. PMC   2231433 . PMID   17934032.
73. Rathgeb-Fuetsch M, Kempter G, Feil A, Pollmächer T, Schuld A (September 2011). "Short- and long- term efficacy of cognitive behavioral therapy for DSM-IV panic disorder in patients with and without severe psychiatric comorbidity". Journal of Psychiatric Research. 45 (9): 1264–8. doi:10.1016/j.jpsychires.2011.03.018. PMID   21536308.
74. American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders (4th, text revision (DSM-IV-TR) ed.). ISBN   0-89042-025-4.
75. Marks, Isaac M.; Swinson, Richard P.; Başoǧlu, Metin; Kuch, Klaus; Noshirvani, Homa; O'Sullivan, Geraldine; Lelliott, Paul T.; Kirby, Marlene; McNamee, Gary; Sengun, Seda; Wickwire, Kim (June 1993). "Alprazolam and Exposure Alone and Combined in Panic Disorder with Agoraphobia: A Controlled Study in London and Toronto". British Journal of Psychiatry. 162 (6): 776–787. doi:10.1192/bjp.162.6.776. PMID   8101126. S2CID   25233822.
76. Milrod BL, Leon AC, Barber JP, Markowitz JC, Graf E (June 2007). "Do comorbid personality disorders moderate panic-focused psychotherapy? An exploratory examination of the American Psychiatric Association practice guideline". The Journal of Clinical Psychiatry. 68 (6): 885–91. doi:10.4088/JCP.v68n0610. PMID   17592913.
77. Barlow DH, Gorman JM, Shear MK, Woods SW (May 2000). "Cognitive-behavioral therapy, imipramine, or their combination for panic disorder: A randomized controlled trial". JAMA. 283 (19): 2529–36. doi:10.1001/jama.283.19.2529. PMID   10815116.
78. Watanabe, Norio; Churchill, Rachel; Furukawa, Toshi A (21 January 2009). "Combined psychotherapy plus benzodiazepines for panic disorder". Cochrane Database of Systematic Reviews (1): CD005335. doi:10.1002/14651858.CD005335.pub2. PMID   19160253.
79. Busch, Fredric N.; Milrod, Barbara L. (1 February 2008). "Panic-Focused Psychodynamic Psychotherapy". Psychiatric Times. 25 (2).
80. Schmidt, Norman B.; Woolaway-Bickel, Kelly; Trakowski, Jack; Santiago, Helen; Storey, Julie; Koselka, Margaret; Cook, Jeff (2000). "Dismantling cognitive–behavioral treatment for panic disorder: Questioning the utility of breathing retraining". Journal of Consulting and Clinical Psychology. 68 (3): 417–424. CiteSeerX   10.1.1.561.9948 . doi:10.1037/0022-006x.68.3.417. PMID   10883558.
81. "Panic Disorder". National Institute of Mental Health. Archived from the original on 28 April 2006. Retrieved 12 May 2006.
82. van Apeldoorn, F. J.; van Hout, W. J. P. J.; Mersch, P. P. A.; Huisman, M.; Slaap, B. R.; Hale, W. W.; Visser, S.; van Dyck, R.; den Boer, J. A. (April 2008). "Is a combined therapy more effective than either CBT or SSRI alone? Results of a multicenter trial on panic disorder with or without agoraphobia". Acta Psychiatrica Scandinavica. 117 (4): 260–270. doi:10.1111/j.1600-0447.2008.01157.x. hdl: 1874/385414 . PMID   18307586. S2CID   23376651.
83. Gloster, Andrew T.; Wittchen, Hans-Ulrich; Einsle, Franziska; Lang, Thomas; Helbig-Lang, Sylvia; Fydrich, Thomas; Fehm, Lydia; Hamm, Alfons O.; Richter, Jan; Alpers, Georg W.; Gerlach, Alexander L.; Ströhle, Andreas; Kircher, Tilo; Deckert, Jürgen; Zwanzger, Peter; Höfler, Michael; Arolt, Volker (2011). "Psychological treatment for panic disorder with agoraphobia: A randomized controlled trial to examine the role of therapist-guided exposure in situ in CBT". Journal of Consulting and Clinical Psychology. 79 (3): 406–420. doi:10.1037/a0023584. PMID   21534651.
84. Koszycki, D.; Taljaard, M.; Segal, Z.; Bradwejn, J. (February 2011). "A randomized trial of sertraline, self-administered cognitive behavior therapy, and their combination for panic disorder". Psychological Medicine. 41 (2): 373–383. doi:10.1017/S0033291710000930. PMID   20462466. S2CID   36613894.
85. Nolen-Hoeksema S (1 January 2014). Abnormal Psychology. McGraw-Hill Education – Europe. ISBN   978-1-259-06072-4.^{[ page needed ]}
86. Seguí J, Márquez M, Canet J, García L (1999). "Causas de fracaso en el tratamiento psicofarmacologico del trastorno por angustia" [Causes of failure in psychopharmacological treatment of anxiety disorder]. Actas Españolas de Psiquiatría (in Spanish). 27 (4): 250–258. PMID   10469946.
87. Barlow, David H.; Gorman, Jack M.; Shear, M. Katherine; Woods, Scott W. (17 May 2000). "Cognitive-Behavioral Therapy, Imipramine, or Their Combination for Panic Disorder: A Randomized Controlled Trial". JAMA. 283 (19): 2529–36. doi:10.1001/jama.283.19.2529. PMID   10815116.
88. Wiborg, Ida M.; Dahl, AA (1 August 1996). "Does Brief Dynamic Psychotherapy Reduce the Relapse Rate of Panic Disorder?". Archives of General Psychiatry. 53 (8): 689–94. doi:10.1001/archpsyc.1996.01830080041008. PMID   8694682.
89. Lewis, Catrin; Pearce, Jennifer; Bisson, Jonathan I. (January 2012). "Efficacy, cost-effectiveness and acceptability of self-help interventions for anxiety disorders: systematic review". British Journal of Psychiatry. 200 (1): 15–21. doi: 10.1192/bjp.bp.110.084756 . PMID   22215865.
90. Moylan, Steven; Giorlando, Francesco; Nordfjærn, Trond; Berk, Michael (March 2012). "The role of alprazolam for the treatment of panic disorder in Australia". Australian & New Zealand Journal of Psychiatry. 46 (3): 212–224. doi:10.1177/0004867411432074. PMID   22391278. S2CID   11006795.
91. Goodwin, R.D.; Faravelli, C.; Rosi, S.; Cosci, F.; Truglia, E.; de Graaf, R.; Wittchen, H.U. (August 2005). "The epidemiology of panic disorder and agoraphobia in Europe". European Neuropsychopharmacology. 15 (4): 435–443. doi:10.1016/j.euroneuro.2005.04.006. PMID   15925492. S2CID   14905286.
92. Beamish, Patricia M.; Granello, Darcy Haag (July 2002). "Belcastro". Amy L. 24 (3): 224. Retrieved 6 February 2023.
93. Ziffra, Michael (May 2021). "Panic disorder: A review of treatment options". Annals of Clinical Psychiatry. 33 (2): 124–133. PMID   33529291 . Retrieved 27 May 2024.
94. "Clinical guidelines and evidence review for panic disorder and generalised anxiety disorder" (PDF). National Collaborating Centre for Primary Care. 2004. Archived (PDF) from the original on 19 February 2009. Retrieved 16 June 2009.
95. Damsa, Cristian; Lazignac, Coralie; Iancu, Ruxandra; Niquille, Marc; Miller, Nick; Mihai, Adriana; Virgillito, Salvatore; Adam, Eric (2008). "Troubles paniques: du diagnostic différentiel vers une prise en charge urgente" [Panic disorders: differential diagnosis and care in emergencies]. Revue Médicale Suisse (in French). 4 (144): 404–409. doi:10.53738/REVMED.2008.4.144.0404. PMID   18320769.
96. Bandelow B, Zohar J, Hollander E, Kasper S, Möller HJ (October 2002). "World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the pharmacological treatment of anxiety, obsessive-compulsive and posttraumatic stress disorders". The World Journal of Biological Psychiatry. 3 (4): 171–99. doi: 10.3109/15622970209150621 . PMID   12516310.
97. Bruce SE, Vasile RG, Goisman RM, Salzman C, Spencer M, Machan JT, Keller MB (August 2003). "Are benzodiazepines still the medication of choice for patients with panic disorder with or without agoraphobia?". The American Journal of Psychiatry. 160 (8): 1432–8. doi:10.1176/appi.ajp.160.8.1432. PMID   12900305.
98. Stevens JC, Pollack MH (2005). "Benzodiazepines in clinical practice: consideration of their long-term use and alternative agents". The Journal of Clinical Psychiatry. 66. 66 (Suppl 2): 21–7. PMID   15762816.
99. Work Group on Panic Disorder (January 2009). "APA Practice Guideline for the Treatment of Patients With Panic Disorder, Second Edition" (PDF). Retrieved 12 July 2009.
100. School Of Health Related Research (Scharr), University of Sheffield (2004). Clinical Guidelines for the Management of Anxiety: Management of Anxiety. National Institute for Health and Clinical Excellence: Guidance. National Collaborating Centre for Primary Care. OCLC   708544131. PMID   20945576.^{[ page needed ]}
101. Breilmann J, Girlanda F, Guaiana G, Barbui C, Cipriani A, Castellazzi M, et al. (March 2019). "Benzodiazepines versus placebo for panic disorder in adults". The Cochrane Database of Systematic Reviews. 3 (3): CD010677. doi:10.1002/14651858.CD010677.pub2. PMC   6438660 . PMID   30921478.
102. Bruce MS, Lader M (February 1989). "Caffeine abstention in the management of anxiety disorders". Psychological Medicine. 19 (1): 211–4. doi:10.1017/S003329170001117X. PMID   2727208. S2CID   45368729.
103. Prasad, Chandan (2005). Nutritional Neuroscience. CRC Press. p. 351. ISBN   978-0-415-31599-9 . Retrieved 7 October 2012.
104. Nehlig A (2004). Coffee, Tea, Chocolate, and the Brain. CRC Press. p. 136. ISBN   978-0-415-30691-1 . Retrieved 7 October 2012.
105. Juliano, Laura M.; Griffiths, Roland R. (1 October 2004). "A critical review of caffeine withdrawal: empirical validation of symptoms and signs, incidence, severity, and associated features". Psychopharmacology. 176 (1): 1–29. doi:10.1007/s00213-004-2000-x. PMID   15448977. S2CID   5572188.
106. "Facts about Panic Disorder". National Institute of Mental Health. Archived from the original on 7 September 2006. Retrieved 30 September 2006.
107. Lähdepuro, Anna; Savolainen, Katri; Lahti-Pulkkinen, Marius; Eriksson, Johan G.; Lahti, Jari; Tuovinen, Soile; Kajantie, Eero; Pesonen, Anu-Katriina; Heinonen, Kati; Räikkönen, Katri (13 March 2019). "The Impact of Early Life Stress on Anxiety Symptoms in Late Adulthood". Scientific Reports. 9 (1): 4395. Bibcode:2019NatSR...9.4395L. doi:10.1038/s41598-019-40698-0. PMC   6416302 . PMID   30867476.
108. Ayuso-Mateos JL. "Global burden of panic disorder in the year 2000" (PDF). World Health Organization. Archived (PDF) from the original on 28 October 2013. Retrieved 27 February 2013.
109. Moreau DL, Follet C (1993). "Panic disorder in children and adolescents". Child Adolesc Psychiatr Clin N Am. 2 (4): 581–602. doi:10.1016/S1056-4993(18)30527-3. PMID   1530067.
110. Diler RS, Birmaher B, Brent DA, Axelson DA, Firinciogullari S, Chiapetta L, Bridge J (2004). "Phenomenology of panic disorder in youth". Depression and Anxiety. 20 (1): 39–43. doi: 10.1002/da.20018 . PMID   15368595. S2CID   23612310.
111. Alessi NE, Magen J (November 1988). "Panic disorder in psychiatrically hospitalized children". The American Journal of Psychiatry. 145 (11): 1450–2. doi:10.1176/ajp.145.11.1450. PMID   3189608.
112. Biederman J, Faraone SV, Marrs A, Moore P, Garcia J, Ablon S, et al. (February 1997). "Panic disorder and agoraphobia in consecutively referred children and adolescents". Journal of the American Academy of Child and Adolescent Psychiatry. 36 (2): 214–23. doi:10.1097/00004583-199702000-00012. PMID   9031574.
113. Essau CA, Conradt J, Petermann F (1999). "Frequency of panic attacks and panic disorder in adolescents". Depression and Anxiety. 9 (1): 19–26. doi:10.1002/(SICI)1520-6394(1999)9:1<19::AID-DA3>3.0.CO;2-#. PMID   9989346. S2CID   23669841.
114. King NJ, Gullone E, Tonge BJ, Ollendick TH (January 1993). "Self-reports of panic attacks and manifest anxiety in adolescents". Behaviour Research and Therapy. 31 (1): 111–6. doi:10.1016/0005-7967(93)90049-Z. PMID   8417721.
115. Macauly JL, Kleinknecht RA (1989). "Panic and panic attacks in adolescents". J Anxiety Disord. 3 (4): 221–41. doi:10.1016/0887-6185(89)90016-9.
116. de Reiter C, Rifkin H, Garssen B, Van Schawk A (1989). "Comorbidity among the anxiety disorders". J Anxiety Disord. 3 (2): 57–68. doi:10.1016/0887-6185(89)90001-7.
117. Last CG, Strauss CC (1989). "Panic disorder in children and adolescents". J Anxiety Disord. 3 (2): 87–95. doi:10.1016/0887-6185(89)90003-0.
118. Beidel, D.C.; Alfano, C.A. (2018) [2011]. Child Anxiety Disorders: A Guide to Research and Treatment (2nd ed.). Routledge. ISBN   978-1-138-37797-4.
119. Lewin, Adam B. (2011). "Parent Training for Childhood Anxiety". Handbook of Child and Adolescent Anxiety Disorders. pp. 405–417. doi:10.1007/978-1-4419-7784-7_27. ISBN   978-1-4419-7782-3.

External links

• Panic disorder at Curlie