5.2 Panic Disorder & Agoraphobia – Comprehensive Study Notes

Distinguishing Anxiety, Panic & Panic Disorder

• Anxiety (generalized)

  • Lower-grade, pervasive, long-lasting; may persist for days.

  • Onset tends to be gradual; intensity moderate.

• Panic

  • Brief but extremely intense “false alarm.”

  • Sudden onset, peaks within $\approx 10\,\text{min}$; subsides within $20–30\,\text{min}$ (rarely > $60\,\text{min}$).

  • Strong somatic focus: heart, respiration, gastrointestinal, vasomotor sensations.

• Panic Disorder (PD)

  • Characterised by recurrent, unexpected panic attacks plus persistent concern, worry, or behavioural change lasting $\ge 1\,\text{month}$.

  • More intense and rapid-onset than Generalised Anxiety Disorder (GAD).

DSM-5 Diagnostic Criteria – Panic Disorder

• Criterion A – Recurrent, unexpected panic attacks (see symptom list below).

• Criterion B – At least one attack followed by $\ge 1$ month of either:

  • Persistent concern/worry about additional attacks or consequences (e.g., “going crazy,” heart attack).

  • Significant maladaptive behaviour change (e.g., avoiding exercise, unfamiliar places).

• Criterion C – Disturbance not due to substance/medication or medical condition (e.g., hyperthyroidism, cardiopulmonary disease).

• Criterion D – Not better explained by another mental disorder (social anxiety, specific phobia, OCD, PTSD, separation anxiety, etc.).

Panic Attack – Required Symptom List (≥ 4 of 13)

Abrupt surge can arise from calm or anxious state.

1. Palpitations / pounding / accelerated heart rate.

2. Sweating.

3. Trembling or shaking.

4. Shortness of breath / smothering.

5. Feeling of choking.

6. Chest pain or discomfort.

7. Nausea or abdominal distress (more common in women during cardiac events).

8. Dizziness, unsteadiness, light-headedness, or faintness.

9. Chills or heat sensations.

10. Paresthesia (numbness/tingling).

11. Derealisation (unreality) or depersonalisation (detached from self).

12. Fear of losing control or “going crazy.”

13. Fear of dying.

• Culture-specific symptoms (e.g., tinnitus, neck soreness, uncontrollable screaming) may appear but do not count toward the required four.

DSM-5 Diagnostic Criteria – Agoraphobia (Separate Diagnosis)

• Fear/anxiety about situations where escape may be difficult or help unavailable if panic-like symptoms occur.

• Must involve ≥ 2 of 5 situation clusters:

  1. Using public transport (cars, buses, trains, ships, planes).

  2. Being in open spaces (parking lots, bridges).

  3. Being in enclosed spaces (shops, cinemas).

  4. Standing in line / being in a crowd.

  5. Being outside home alone.

• Situations almost always provoke fear; are actively avoided, endured with distress, or require a companion.

• Fear is out of proportion; lasts ≥ $6\,\text{months}$; causes significant distress/impairment.

• Not better explained by another disorder or medical condition.

• Diagnosed independently of Panic Disorder; if both criteria met, assign both diagnoses.

Epidemiology & Course

• Lifetime prevalence of PD: $4.7\%$ of adults.

• Age of onset: typically $20–40\,\text{yrs}$ (can begin late teens).

• Course: chronic, disabling; intensity may wax and wane.

  • 12-year study: $58\%$ who recovered later relapsed.

• Panic attacks (single episode) far more common: $\approx 23\%$ of adults experience ≥ 1, but only $4–5\%$ develop PD.

• First attack often follows major stressor; $80–90\%$ report negative life event before initial attack (loss, victimisation, etc.).

Gender & Sociocultural Factors

• PD ≈ 2 × as prevalent in women as men.

• Agoraphobia: severity correlates with female preponderance; severe cases $80–90\%$ female.

• Sociocultural account: avoidance and need for a companion more socially permissible for women; men more likely to “tough it out” or self-medicate (nicotine, alcohol).

Comorbidity & Suicide Risk

• $83\%$ of PD patients have ≥ 1 additional disorder:

  • GAD, Social Anxiety Disorder, Specific Phobia, PTSD.

  • Major Depression (occurs in $50–70\%$ of PD cases).

  • Substance-use disorders (notably smoking, alcohol).

  • Dependent & Avoidant Personality Disorders.

• PD is an independent predictor of suicidal ideation & attempts (Nock et al., $2009$, $2010$) even after controlling for comorbidities.

Etiology – Integrated View

• Genetic / Temperamental

  • Trait neuroticism & behavioural inhibition elevate risk.

• Brain Circuitry

  • Amygdala hyperactivation.

  • Noradrenergic & serotonergic systems implicated:

  • Locus coeruleus (NE) stimulation → cardiovascular surge.

  • Serotonin inhibits NE; SSRIs ↑ 5-HT → ↓ NE activity.

  • GABA (inhibitory) abnormally low in cortex.

• Cognitive Theory (Clark)

  • Hyper-sensitivity to bodily sensations + catastrophic misinterpretation (e.g., “palpitations = heart attack”).

  • Automatic thoughts fuel vicious cycle → escalating anxiety → full panic.

• Learning Theory

  • Initial attack conditions internal (interoceptive) & external cues → conditioned stimuli.

  • Generalisation and impaired inhibitory learning slow extinction, promoting anticipatory anxiety and agoraphobic avoidance.

Nocturnal Panic Attacks

• Occur in $20–40\%$ of PD patients.

• Abrupt awakening from sleep in panic, typically during Stage 2 / early Stage 3 non-REM (few hours after sleep onset).

• Distinct from:

  • Nightmares (REM).

  • Night Terrors (children, Stage 3–4, minimal awareness).

  • Sleep Paralysis (REM–wake transition, immobility).

• Associated with greater overall severity, insomnia, frequent awakenings.

Psychological Treatments

• Exposure-Based Therapy

  • Graduated in-vivo exposure to avoided situations.

  • $60–75\%$ achieve clinically significant improvement; gains persist ≥ $2\,\text{yrs}$.

• Interoceptive (Paresthetic) Exposure

  • Deliberate induction of feared bodily sensations (e.g., spinning in chair, hyperventilating, running in place) until habituation.

• Panic Control Treatment (PCT – CBT variant)

  1. Psychoeducation: adaptive nature of anxiety/panic.

  2. Breathing retraining: slow diaphragmatic breathing.

  3. Cognitive restructuring: identify & challenge catastrophic thoughts.

  4. Exposure to feared situations & sensations.

  • Outcome: $70–90\%$ panic-free after $8–14$ weeks; superior to exposure-only; effective for nocturnal panic.

Pharmacological Treatments

• Anxiolytics (Benzodiazepines – e.g., Xanax, Klonopin)

  • Onset: $30–60\,\text{min}$; useful for acute attacks.

  • Side-effects: sedation, cognitive/motor impairment, dependency, withdrawal, high relapse → not first-line.

• Antidepressants

  • Tricyclics, SSRIs, SNRIs (e.g., fluoxetine, sertraline).

  • Advantages: no physiological dependence; treat comorbid depression.

  • Delayed onset: $\approx 4\,\text{weeks}$.

  • Side-effects: dry mouth, constipation, sexual dysfunction; adherence issues.

  • SSRIs preferred; relapse still possible when discontinued.

Combined & Novel Approaches

• Short-term combination (CBT + medication) may slightly outperform monotherapies; reduces side-effects & drop-outs.

• Long-term: reliance on medication alone → higher relapse after discontinuation; CBT fosters durable self-efficacy.

• D-cycloserine (DCS) – partial NMDA agonist; shown to enhance exposure-based learning for PD, specific & social phobias.

Remember: Panic Disorder reflects interplay of biological sensitivity, catastrophic cognition, and learned avoidance. Durable recovery usually requires cognitive-behavioural interventions that dismantle the vicious cycle, sometimes augmented—but not replaced—by pharmacotherapy.