The Nature of Panic
Panic attacks are discrete occurrences of intense fear or discomfort of sudden onset that are accompanied by a surge of physiological hyperarousal. Panic is the clearest clinical presentation of fear. In addition to strong autonomic arousal, panic is characterized by a faulty verbal or imaginal ideation of physical or mental catastrophe (e.g., dying, going insane), intense uncontrollable anxiety, and a strong urge to escape. So aversive is the panic experience that many patients have a strong apprehension about having another attack and develop extensive avoidance of situations thought to trigger panic. As a result panic and agoraphobia are closely associated, with most individuals with panic disorder presenting with some degree of agoraphobic avoidance and 95% of people with agoraphobia reporting a past or current panic disorder. In the latest epidemiological study panic disorder had a 12-month prevalence of 2.7%, whereas agoraphobia without panic disorder was much less common at 0.8%.
DSM-V defines panic attacks as “a discrete period of intense fear or discomfort in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes”. The typical panic attack lasts between 5 and 20 minutes, although a heightened state of anxiety can linger long after the panic episode subsides (Rachman, 2004). According to DSM-IV, the defining symptoms of panic are:
• Elevated heart rate or palpitations
• Sweating
• Trembling or shaking
• Smothering sensation or shortness of breath
• Feeling of choking
• Chest tightness, pain, or discomfort
• Abdominal distress or nausea
• Dizziness, lightheadedness, faintness, or feeling unsteady
• Feelings of unreality (derealization) or detachment from oneself (depersonalization)
• Numbness or tingling sensations
• Chills or hot flushes
• Fear of losing control or going crazy
• Fear of dying
Situational Triggers
Even though DSM-IV specifies that two unexpected panic attacks must occur to meet diagnostic criteria for panic disorder, the majority of panic episodes are anticipated
because they are provoked by exposure to an identifiable stressor. Theaters, supermarkets, restaurants, department stores, buses, trains, airplanes, subways, driving in the car, walking on the street, staying alone at home, or being far away from home are all examples of external situations that individuals with panic disorder report may trigger a panic attack. As a result these situations are often avoided in order to minimize the possibility of triggering a panic episode. More recently, researchers have argued that internal cues such as thoughts, images, feelings, or bodily sensations can trigger panic and avoidance.
Acute Physiological Arousal
Although an abrupt onset of physiological symptoms is one of the hallmarks of panic attacks, it is clearly not a defining feature of the disorder. Individuals with panic disorder are not more autonomically hyperactive to standard laboratory stressors than nonpanickers. Furthermore, even though 24-hour ambulatory heart rate monitoring of panic patients indicates that most panic attacks involve a distinct elevation in heart rate, a significant minority of self-reported attacks (i.e., 40%) are not associated with actual increase in heart rate or other physiological responses and most episodes of physiological hyperarousal (i.e., tachycardia) occur without self-reported panic episodes. Moreover, individuals with panic disorder do not have more cardiac arrhythmias in a 24-hour period than nonpanic patients investigated for heart palpitations. As discussed below, it is not the presence of physiological symptoms that is critical in the pathogenesis of panic but rather how these symptoms are interpreted.
Hypervigilance of Bodily Sensations
Empirical studies are inconsistent on whether panic disorder is characterized by heightened interoceptive acuity especially in terms of cardiac perception, although individuals may be more sensitive to the particular body sensations linked to their central fear (e.g., increased pulse rate for those afraid of heart attacks. Fearing bodily sensations does not mean that a person will necessarily be better at detecting interoceptive cues. On the other hand, individuals with panic have heightened anxiety sensitivity and greater vigilance for the physical sensations associated with anxiety. We can conclude from this that panic is characterized by a heightened vigilance and responsiveness to specific physical symptoms linked to a core fear but it is unclear whether individuals with panic disorder are better at detecting changes in their physical state.
Catastrophic Interpretations
A key feature of panic episodes is the tendency to interpret the occurrence of certain bodily sensations in terms of an impending biological (e.g., death), mental (i.e., insanity), or behavioral (e.g., loss of control) disaster (Beck, 1988; Beck & Greenberg, 1988; D. M. Clark, 1986a). For example, individuals with panic disorder may interpret (a) chest pain or a sudden increase in heart rate as sign of a possible heart attack, (b) shaking or trembling as a loss of control, or (c) feelings of unreality or depersonalization as a sign of mental instability or “going crazy.” Catastrophic misinterpretations are discussed more fully in our review of the cognitive research.
Apprehension of Panic
Individuals with panic disorder report extreme distress, even terror, during panic attacks and so quickly develop considerable apprehension about having future attacks. This fear of panic is a distinguishing feature of the disorder and is included in DSM-IV-TR as a diagnostic criterion. Presence of fear and avoidance of panic attacks differentiates panic disorder from other anxiety disorders in which panic attacks occur but the “fear of panic” is missing.
Extensive Safety Seeking and Avoidance
Safety-seeking behavior and avoidance of panic-related situations are common responses to panic attacks and may be seen as coping strategies to prevent the impending disaster (e.g., overwhelming panic, a heart attack, loss of control). Phobic avoidance is common in panic disorder and is elicited by the anticipation of panic attacks in particular. The phobic situations associated with agoraphobia are quite variable across individuals because the avoidance is elicited by the anticipation of panic attacks and not by the situations themselves. 98% of panic disorder cases have mild to severe situational avoidance, 90% experiential avoidance (i.e., use safety signals or thought strategies to withdraw or minimize contact with a phobic stimulus), and 80% interoceptive avoidance (i.e., refusal of substances or activities that could produce the physical sensations associated with panic). Furthermore, they found that severity of agoraphobic avoidance was predicted by elevated fear of physical symptoms of anxiety (i.e., anxiety sensitivity) and low perceived control over threat. Together these findings indicate a close but complicated relationship between panic attacks and the development of avoidance responses.
Perceived Lack of Control
A striking characteristic of panic attacks is the feeling of being overwhelmed by uncontrollable anxiety. This apparent loss of control over one’s emotions and the anticipated threat causes a fixation on the panicogenic sensations and a loss of capacity to use reason to realistically appraise one’s physical and emotional state.
Panic Distinct from Anxiety
Panic should not be seen as an extreme form of anxiety involving the anticipation of future threat but rather as an immediate “fight-or-flight” response to perceived imminent danger. Panic attacks would fall within the “immediate fear response” (Phase I), whereas apprehension about panic, avoidance, and safety-seeking would constitute secondary processes (Phase II) that maintain a state of heightened anxiety about having panic attacks.
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