Imagine yourself driving to work or standing in the supermarket check-out line, waiting to pay for your groceries. Suddenly, you experience a powerful sensation, similar to what you would be feeling if your car broke down on a railroad track, with a freight train hurtling towards you. Your heart is pounding, your chest feels tight and you experience a suffocating feeling. Your vision becomes clouded – everything you see around you becomes blurry or seems unreal. You think you might be having a heart attack, dying or losing self-control or contact with reality.
Afraid of losing control of your vehicle or breaking down in the store, you flee as quickly as possible. After a few minutes, the feeling of panic subsides. You calm down and wonder, What just happened to me? Moreover, for over a month now, you are scared of experiencing another of these episodes. This is what we call a panic attack.
Panic attacks have been described as a signal triggered by the body without valid reason – like a false alarm. When such a signal is triggered in the presence of real and imminent danger, the reaction of extreme terror may be critical to survival. But in the case of a panic attack, this terrified reaction occurs in the absence of any real danger.
A strange and terrifying characteristic of panic attacks is that they frequently occur in familiar settings or situations that present no real danger. Nevertheless, the feeling of extreme terror that grips the victim, with all of its attendant physical and psychological symptoms, is all too real.
Without detection and treatment, a panic disorder may progress and cause greater distress. The constant threat of not knowing when or where the next attack will strike can cause anticipatory anxiety, the persistent fear of experiencing another panic attack. Sufferers may discover that simply avoiding dreaded situations or locations does little to prevent this feeling of anxiety or fear.
For a panic disorder to be diagnosed, this negative anticipation of further panic attacks must persist for a month or longer.
From a medical perspective, a panic attack must include a minimum of four (or more) of the following symptoms, peaking in less than 10 minutes:
- trembling or shaking
- sensations of shortness of breath or smothering
- a choking feeling
- chest pain or tightness
- nausea or abdominal distress
- feeling dizzy, unsteady, lightheaded or faint
- derealization (feelings of unreality) or depersonalization (being detached from oneself)
- fear of losing control or going crazy
- fear of dying
- numbness or tingling in the hands
- chills or hot flashes
The DSM-IV lists the characteristics of panic disorder (with or without agoraphobia) as follows:
The individual has experienced the following:
- Recurrent, unexpected panic attacks.
- At least one of the attacks has been followed by 1 month (or more) of one (or more) of the
- Persistent concern about having additional attacks;
- Concern surrounding the implications of the attack or its consequences;
- Significant behavioural changes related to these attacks.
The presence or absence of agoraphobia.
The panic attacks may not attributed to the abusive consumption of controlled substances or to a generalized physical condition.
The panic attacks are not linked to another mental disorder.
Panic attacks may be present in other anxiety disorders such as social phobia or specific phobias. For example, in a person with arachnophobia, a panic attack may be triggered by the sight of a spider. However, although specific situations or experiences may trigger panic attacks in individuals suffering from panic disorder, randomly-triggered panic attacks must be present for the diagnosis to be confirmed.
Agoraphobia may or may not accompany panic disorder.
Agoraphobia is the fear of finding oneself in a place or situation where it would be difficult to flee or to obtain help during a panic attack. Some agoraphobes only move within a restricted perimeter or must be accompanied at all times by someone they trust. As a result, the disorder affects the agoraphobe’s friends and loved ones as well. Others face the danger, but pay the price of high anxiety levels.
Typically, victims of panic disorder remember their first panic attacks quite well, since the physical and psychological terror was crushing. A few believe they were experiencing massive heart attacks or were in the process of losing their minds. The impulse to flee immediately or to seek help drives some victims towards hospital emergency departments, where they insist that they feared they were experiencing a heart attack, for example. Normally, medical tests do not reveal any abnormalities.
The suddenness and violence of panic attacks lead some victims to avoid situations or locations where they suffered an attack in the past. They may feel that highways or grocery stores are terrifying places. These victims convince themselves that in the event of another attack, at least they will not be driving, in a crowd, or enclosed in a train or airplane, where it would be difficult to flee or seek the help they need. Victims will avoid certain activities or locations due to fear of having an attack or losing control. This is called agoraphobic avoidance. For example, these individuals may end up avoiding staying home alone, walking through their neighbourhoods, visiting the supermarket, the bank, the mall or the movies, going to the theatre, using public transportation, driving, crossing bridges or tunnels, flying or travelling. The restrictive effect on victims’ personal and professional lives can become significant.
The consequences may be serious
If left untreated, panic attacks, anticipatory anxiety and agoraphobic avoidance may lead to serious consequences. Victims of this disorder exhibit higher susceptibility to depression than the general population, with all the attendant complications this entails. In their desperate efforts to quell these attacks and as a result of the anticipatory anxiety they are experiencing, some victims resort to abusing alcohol, drugs or certain medications.
Panic disorder typically presents in late adolescence or early adulthood. The first attack may occur following a period of severe stress, such as the loss of a loved one through death or separation, an illness, an accident or a birth. Although the stressful situation is overcome, the panic attacks persist.
Panic disorder has no single cause; rather, it results from a combination of genetic, biological and psychosocial factors.
Researchers continue to attempt to pinpoint the origins and underlying causes of panic disorder.
Current research is focussed on identifying more effective methods for diagnosing and treating panic disorder.
Specialists are also eager to answer questions such as:
- Why are panic attacks triggered at specific times and not at others?
- What role do hereditary factors play?
How can we rationalize the apparent variations between male and female panic disorder sufferers?
Who is at risk?
Panic disorder generally appears in late adolescence or early adulthood, affecting between 1.5-3.5% of the population. Women are twice as likely as men to suffer from panic disorder and three times more likely than men to receive a diagnosis of panic disorder without agoraphobia.
Recent calculations indicate that over one million Canadians suffer from panic disorder with or without agoraphobia. Precise numbers are difficult to pinpoint, since sufferers often mask their condition, and a considerable number of health professionals fail to diagnose it.
In fact, panic disorder has been described as one of medicine’s “great imposters”, as it is easily confused with a number of other medical and psychiatric conditions. A national study revealed that individuals suffering from panic disorder seek out medical attention more often and more quickly than those afflicted with other anxiety disorders. Victims will often consult several different physicians, without clear outcomes. Feeling misunderstood and embarrassed, some give up all hope of improvement or treatment.
However, 34% of individuals sought treatment within one year of the initial presentation of the disorder; for people who sought later treatment, the average wait for a consult is 10 years.
Individuals suffering from panic disorder are twice as likely to attempt suicide or harbour suicidal thoughts (ideation) than those with other psychiatric disorders. They are nearly 20 times as likely to do so as individuals without psychiatric disorders.
Prevention and care
A number of proven treatments currently exist, providing hope for quicker and more effective therapies for individuals suffering from panic disorder. All effective treatments begin with an accurate diagnosis. The simple act of identifying the condition can offer a profound sense of relief to individuals who fear that their issues are not being taken seriously.
The first step in treating panic disorder is a review of personal health practices. A healthy lifestyle may vastly reduce anxiety and enable it to revert back to tolerable levels.
Desirable health practices include:
- Proper balance between work, rest and leisure activities;
- Low consumption of alcohol, caffeine and nicotine;
- Good nutrition; and
- Most importantly, regular exercise.
Significant levels of disability and high rates of suicidal ideation, suicide attempts, substance use/abuse and depression frequently accompany panic disorder.
Primary treatments include cognitive-behavioural therapy and drug therapy.
Cognitive-behavioural therapy is considered the most effective treatment for panic disorder. The therapy’s objectives seek to reduce the frequency and severity of panic attacks as well as the levels of anticipatory anxiety, phobic avoidance associated with panic, and functional impairment related to anxiety.
In cognitive-behavioural therapy, patients (in groups or on their own) are gradually exposed to specific agoraphobic situations they most fear.
Should a panic attack be triggered, patients learn to recognize the warning signs of this attack, correctly interpret the symptoms and remain present in the situation rather than flee. They also learn to dispel their fears and better grasp the situation. This therapy aims to change patients’ thought patterns by helping them analyze their feelings and distinguish between realistic and unrealistic thoughts.
- Medication therapy
Antidepressants are effective against severe panic, anticipatory anxiety and agoraphobic avoidance, and in improving factors such as disability levels and quality of life.
Antidepressants are as effective as cognitive-behavioural therapy in the treatment of depressive disorders and other anxiety disorders which often accompany panic disorder.
Anti-anxiety agents such as benzodiazepines
Effective when anxiety and agitation levels are high. However, they are considered short-term solutions only, due to their side effects and the potential for addiction.
Relaxation techniques and meditation: Breathing exercises can act quickly on anxiety and decrease the patient’s overall stress level after only a few weeks of regular practice. These exercises form the basis for most relaxation techniques; the key is regular practice, ideally twice daily. As time goes on, the degree of anxiety decreases and energy levels rise. Relaxation techniques are plentiful, and have been shown to reduce stress and anxiety in general.
Meditation encourages individuals to focus on their own breathing or on a single word, sound, symbol or image in order to achieve a state of deep relaxation while stimulating mind and spirit. Several types of meditation have been shown to reduce stress.
Bibliotherapy or self-directed therapy: Supplementary reading effectively complements psychotherapy by encouraging patients to broaden their understanding of the disorder’s root causes, nature and treatment.
A. Marchand, A. Letarte: La peur d’avoir peur.
Panic disorder with agoraphobia treatment guide, Éditions Alain Stanké, 2004.
Note : Reading this guide will be effective if the patient performs the recommended exercises.
Support and self-help groups
To help individuals suffering from panic disorder break out of their isolation and interact, share their experiences and receive support and additional information.
Association / Troubles Anxieux du Québec (Anxiety Troubles Association)
Canadian Network for Mood and Anxiety Treatments
L’Ordre des psychologues du Québec (Quebec’s Psychologists Order)
(514) 738-1881 ou 1-888-731-9420
Groupe de Ressources pour le trouble panique (GRTP) – Jonquière
Revivre (Association for people suffering from anxiety, bipolar disorder or depression)
Ligne d’écoute : (514) 738-4873 ou 1.866.REVIVRE
La Clé des Champs (Peer network for people living with an anxiety disorders)
Phobies-Zéro : (Help groups for youth and adults suffering from anxiety disorders – all around Quebec)
Ligne d’écoute et de soutien : (514) 276-3105 ou 1-866-0002
Groupe d’Entraide G.E.M.E. (Help group for better living)
(450) 462-4363, numéro sans frais : 1-866-443-4363
FFAPAMM (Friends and families of people suffering from mental illness)
Association québécoise de prévention du suicide (Suicide prevention)
24 heures/ jour, 7 jours/7 partout au Québec
1-866 APPELLE (277-3553)