ITMHD - panic disorder

panic attack - DSM-5 diagnostic criteria

Feature	Description
Definition	A discrete episode of intense fear or discomfort, with ≥4 symptoms, developing abruptly and reaching peak within 10 minutes.
Symptoms (≥4)	Sweating, trembling, shortness of breath, choking, chest pain, nausea, dizziness, derealisation/depersonalisation, fear of losing control/“going crazy”, fear of dying, paresthesia, chills/hot flushes.

• exam anchor:

  • “peaks within 10 minutes” = PANIC attack.

  • slow onset = ANXIETY attack.

panic attack vs anxiety attack

Feature	Panic Attack	Anxiety Attack	Both
Onset	Sudden, abrupt	Gradual build-up	↑ HR, SOB, sweating
Peak	Within minutes	Does not sharply peak	Nausea, dizziness
Intensity	Very intense, feels life-threatening	Moderate	Chest discomfort
Trigger	Often none	Usually clear trigger	Physical symptoms
Duration	Minutes–hours	Hours–days–weeks	Overlaps
Key Symptom	Fear of dying/losing control	General tension/unrest	Shared arousal

• High-importance distinction:

  • Panic attack = no specific trigger, sudden, intense.

  • Anxiety attack = triggered, gradual, less intense.

prevalence of panic disorder (UK)

Statistic	Value
Prevalence UK	~0.6%–1.7% adults
Age	More common in 16–24 year-olds
Gender	Women > men (consistent with anxiety trends)

models of panic disorder: cognitive theory — Clark (1986).

• core idea: panic attacks result from catastrophic misinterpretation of bodily sensations.

  Step	Example
  Normal bodily sensation	↑ heart rate
  Misinterpretation	“I’m having a heart attack.”
  Anxiety increases	More symptoms
  Positive feedback loop	Full panic attack

• Key terms for exam:

  • “Catastrophic misinterpretation”

  • “Internal cues become perceived as dangerous”

  • “Panic results from fear of bodily sensations”

    • This model forms the basis of CBT for panic disorder.

models of panic disorder: behavioural theory

Component	Description	Key Studies
Classical Conditioning	Neutral cues become associated with panic.	Pavlov (1904); Watson & Rayner (1920)
Operant Conditioning	Avoidance relieves anxiety → negatively reinforces avoidance → panic maintained.	Thorndike (1949), Skinner (1948)

• example:

  • first panic attack occurs on a bus → anxiety becomes conditioned to the bus → avoidance → disorder maintained.

models of panic disorder: psychodynamic theory

Feature	Description
Cause	Unconscious conflict, repressed emotions, early fears.
Panic Attack Function	Defence mechanism; surge of anxiety when repressed material threatens awareness.
Evidence Base	Limited; not a first-line treatment.

models of panic disorder: biopsychosocial theory.

• panic = interaction of:

  • genetic vulnerability

  • cognitive vulnerabilities

  • environmental stressors

• very commonly referenced in clinical exam questions.

models of panic disorder: neurobiological theory

Mechanism	Details
Neurotransmitters	Serotonin, norepinephrine, GABA dysregulation.
Brain Circuits	Amygdala hyperactivity; abnormalities in “fear network.”
Genetics	Strong hereditary component; family history increases risk.

• Classic finding:

  • locus coeruleus (NE centre) involvement in panic symptoms.

  • used in many MCQs.

what makes panic disorder a disorder.

• panic disorder = recurrent unexpected panic attacks + persistent worry or behavioural change.

Requirement	Description
1. Recurrent Unexpected Panic Attacks	Not predictable; no trigger.
2. Persistent Concern	Worry about future attacks (“fear of fear”).
3. Behavioural Change	Avoidance of situations (agoraphobic tendencies).

essential classic studies + theories.

• Clark (1986, 1988) — panic attacks bc of catastrophic misinterpretation of bodily sensations (eg: interpreting increased heart rate as heart attack).

• Barlow’s Triple Vulnerability Model (2002):

  • general biological vulnerability (dimensions of temperament, eg: neuroticism + extraversion).

  • general psychological vulnerability (perceived control over life stress + emotional states).

  • disorder-specific psychological vulnerability (eg: thought-action fusion for OCD).

• Panic Provocation Studies:

  • CO₂ inhalation or lactate infusion can trigger panic in susceptible individuals → supports biological vulnerability.

• Interoceptive Conditioning (Bouton et al.):

  • Internal bodily cues become conditioned stimuli → panic triggered by internal sensations rather than the environment.

interoceptive exposure (core part of CBT).

• CBT repeatedly exposes clients to feared bodily sensations:

Symptom Feared	Exposure Exercise
Racing heart	Running on the spot
Dizziness	Spinning in chair
Breathlessness	Straw breathing
Derealisation	Staring at oneself in mirror

• goal: teach that bodily sensations are not dangerous → breaks catastrophic misinterpretation loop.

treatment overview — CBT.

• Includes:

  • Psychoeducation (fight-or-flight explanation).

  • Interoceptive exposure.

  • Cognitive restructuring.

  • Situational exposure (agoraphobia links).

    • CBT is the most effective long-term treatment.

treatment overview — pharmacological treatment.

Drug Type	Notes
SSRIs	First-line medication; 4–6 weeks; helps long-term.
Benzodiazepines	Very effective short-term, but: addictive, withdrawal issues, rebound anxiety.

• often used early if symptoms are disabling, but tapered quickly.

treatment overview — psychoanalytic therapy

• explores unconscious conflict; not common in mainstream treatment; limited evidence.

treatment overview — third-wave approaches.

• examples:

  • ACT (acceptance of sensations).

  • Mindfulness (detached awareness).

  • Emotion regulation training.

    • useful when catastrophic thinking is persistent.

differential diagnoses — exam favorites.

Condition	Key Distinguishing Feature
Panic disorder	Unexpected panic attacks; fear of bodily sensations.
Social anxiety	Panic occurs in social situations only.
Agoraphobia	Panic related to situations where escape feels difficult.
GAD	Chronic worry; rarely has sudden panic peaks.
Medical	Hyperthyroidism, arrhythmias, asthma can mimic panic.

quick exam anchors — high yield.

• Peak within 10 minutes = panic attack.

• ≥4 of 13 symptoms.

• Panic = no clear trigger.

• Panic disorder = fear of fear, avoidance.

• Clark’s model = catastrophic misinterpretation.

• Behavioural theory = conditioning + avoidance.

• Biological theory = amygdala, GABA, NE, serotonin.

• CBT = interoceptive exposure + cognitive restructuring.

• Benzodiazepines = fast but addictive.

• SSRIs = first-line medication.

• CO₂/lactate studies show biological sensitivity.

• Prevalence UK = 0.6–1.7%, women > men, young adults most at risk.