Panic Attacks And Panic Disorder
Panic attacks are intense episodes of fear or discomfort that reach a peak within minutes, often accompanied by physical and cognitive symptoms such as palpitations, shortness of breath, dizziness, and fears of losing control or dying. Panic disorder occurs when an individual experiences recurrent panic attacks coupled with persistent concern about having more attacks or changes in behavior to avoid them. Panic attacks can occur unexpectedly or be triggered by specific situations. Panic disorder significantly impacts daily functioning and quality of life, leading to avoidance behaviors and, in some cases, agoraphobia. Understanding the psychological and physiological mechanisms underlying panic is critical for effective treatment. Evidence-based approaches such as cognitive behavioral therapy (CBT) have proven to be highly effective in managing panic attacks and panic disorder.
Riding The Wave: Workbook
Riding The Wave: Workbook
Insufficient Self-Control
Insufficient Self-Control
Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (Second Edition): Therapist Guide
Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (Second Edition): Therapist Guide
Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (Second Edition): Client Workbook
Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (Second Edition): Client Workbook
Cognitive Distortions – Unhelpful Thinking Styles (Common)
Cognitive Distortions – Unhelpful Thinking Styles (Common)
Magnification And Minimization
Magnification And Minimization
Exposures For Fear Of Breathlessness
Exposures For Fear Of Breathlessness
Am I Experiencing Panic Disorder?
Am I Experiencing Panic Disorder?
Am I Experiencing Panic Attacks?
Am I Experiencing Panic Attacks?
Attention Training Practice Record
Attention Training Practice Record
What Keeps Fears And Phobias Going?
What Keeps Fears And Phobias Going?
Recognizing Panic Disorder
Recognizing Panic Disorder
Mastery Of Your Anxiety And Panic (Fifth Edition): Workbook
Mastery Of Your Anxiety And Panic (Fifth Edition): Workbook
Mastery Of Your Anxiety And Panic (Fifth Edition): Therapist Guide
Mastery Of Your Anxiety And Panic (Fifth Edition): Therapist Guide
Identifying The Meaning Of Body Sensations
Identifying The Meaning Of Body Sensations
Links to external resources
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Assessment
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Severity Measure For Panic Disorder
| Craske, Wittchen, Bogels, Stein, Andrews, Lebeu | 2013
- Scale – Adult
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Severity Measure For Agoraphobia
| Craske, Wittchen, Bogels, Stein, Andrews, Lebu | 2013
- Scale – Adult
Guides and workbooks
- Panic attacks: what they are and how to stop the next one | Glasgow STEPS
- Panic disorder: patient treatment manual | Clinical Research Unit for Anxiety and Depression (CRUfAD)
- Coping with panic | Charles Young, Alison Hunte, Jessica Newell, Pat Valian | 2011
Information Handouts
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Panic (Information Handouts)
| Centre For Clinical Interventions
- What Is Panic?
- Biology and Psychology of Panic
- The Vicious Cycle of Anxiety
- Breathing Retraining
- Behavioural Experiments (Negative Predictions)
- Situational Exposure
- Physical Sensations and Panic
- What Are Safety Behaviours?
Treatment Guide
- NICE Guidelines For GAD And Panic | NICE | 2011
- Panic disorder: Manual for Improving Access to Psychological Therapy (IAPT) High intensity CBT therapists. | David Clark, Paul Salkovskis | 2009
Worksheets
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Anxiety (Worksheets)
| Centre For Clinical Interventions
- Anxiety Symptoms Record
- Breathing Rate Record
- Monitoring Relaxation
- Situational Exposure Diary
- Making The Connection
- Thought Diary 1
- Thought Diary 2
- Thought Diary 3
- Thought Diary (Tri-Fold)
- Behavioral Experiment Worksheet
-
Panic (Worksheets)
| Centre For Clinical Interventions
- Breathing Rate Record
- Anxiety Symptoms
- Monitoring Relaxation
- Situational Exposure Diary
- Internal Exposure Record
What Are Panic Attacks and Panic Disorder?
Signs and Symptoms of Panic Attacks
According to DSM-5 and ICD-11, the key features of panic attacks include a range of physical and cognitive symptoms:
Palpitations, pounding heart, or accelerated heart rate.
Sweating, trembling, or shaking.
Sensations of shortness of breath or smothering.
Chest pain or discomfort.
Nausea or abdominal distress.
Dizziness, light-headedness, or fainting.
Chills or hot flushes.
Fear of losing control or going crazy.
Fear of dying.
Feelings of unreality (derealization) or detachment from oneself (depersonalization).
Diagnostic Criteria for Panic Disorder
According to DSM-5, panic disorder is characterized by recurrent, unexpected panic attacks. Following at least one of these attacks, individuals experience persistent worry about future attacks or their consequences, such as fear of losing control or having a medical emergency. This worry often leads to significant changes in behavior, such as avoiding situations that might trigger an attack.
The ICD-11 criteria for panic disorder are similar but place greater emphasis on the presence of panic attacks as the defining feature. Unlike DSM-5, ICD-11 does not require that the panic attacks be unexpected, broadening the diagnostic scope.
Panic Attacks vs. Panic Disorder
Panic attacks can occur in various anxiety disorders or independently. Panic disorder is diagnosed when panic attacks are recurrent, unprovoked, and cause significant distress or behavioral change.
Incidence and Predictors of Panic Disorder
The lifetime prevalence of panic disorder is estimated at 2–3% in the general population, with higher rates observed in women (APA, 2013). Panic attacks, however, are more common, affecting up to 11% of individuals annually (Kessler et al., 2006).
Predictors
Stressful Life Events: Traumatic or significant stressful experiences can be a risk factor for the development of panic disorder (e.g., Leskin & Sheikh, 2002).
Personality Traits: High levels of neuroticism or sensitivity to anxiety-related sensations (anxiety sensitivity) (McNally, 2002)
Genetic Vulnerability: A family history of anxiety or mood disorders increases risk (Hettema et al., 2001).
Medical Conditions: Certain physical conditions (e.g., cardiovascular or respiratory disorders) and substance use can contribute to the development of panic attacks.
Psychological Models and Theories of Panic Disorder
Cognitive Model of Panic (Clark, 1986)
This widely accepted model proposes that panic attacks result from the misinterpretation of benign bodily sensations (e.g., increased heart rate) as catastrophic (e.g., “I’m having a heart attack”). This misinterpretation creates a feedback loop that amplifies symptoms and intensifies panic.
Learning Theory (Bouton et al., 2001)
Suggests that panic attacks are conditioned responses to internal or external cues (e.g., a crowded space). Over time, avoidance of these cues maintains the disorder.
Interoceptive Conditioning (Barlow, 2002):
This theory posits that individuals become sensitized to internal bodily sensations (e.g., dizziness) associated with previous panic attacks, leading to heightened fear responses when these sensations are experienced again.
Hyperventilation Theory (Ley, 1985)
Hyperventilation may play a role in triggering panic attacks by causing symptoms like dizziness and shortness of breath, which are misinterpreted as signs of danger. Hyperventilation is still recognized as a factor in some cases of panic attacks, but its role is now viewed as part of a more complex interaction between physiological, cognitive, and behavioral processes.
Psychodynamic Theory
Psychodynamic theory focuses on the psychological dynamics associated with panic disorder, such as unconscious conflicts, disavowed feelings, and fantasies that contribute to panic symptoms (e.g., Busch & Milrod, 2010).
Evidence-Based Psychological Approaches to Panic Disorder
Cognitive Behavioral Therapy (CBT):
CBT is the most supported treatment for panic disorder (Rabasco et al., 2022). It targets the catastrophic misinterpretations of bodily sensations and aims to reduce avoidance behaviors. Techniques include:
Cognitive restructuring: Identifying and challenging catastrophic thoughts.
Interoceptive exposure: Gradual exposure to feared bodily sensations to reduce fear responses.
Behavioral experiments: Testing beliefs about the feared consequences of panic.
Exposure Therapy:
Exposure therapy focuses on gradual exposure to panic-inducing situations or internal sensations (interoceptive exposure) to diminish fear responses over time.
Applied Relaxation:
This approach teaches patients to use relaxation techniques (e.g., diaphragmatic breathing) to counteract physical symptoms of anxiety during panic attacks.
Acceptance and Commitment Therapy (ACT):
ACT encourages individuals to accept their bodily sensations and anxiety-related thoughts without judgment while pursuing valued goals (Eifert & Forsyth, 2005).
Psychodynamic Therapy
Psychodynamic approaches, such as Panic-Focused Psychodynamic Psychotherapy (PFPP; Milrod et al., 2007), seek to explore the feelings and subjective experiences associated with panic episodes, helping patients address the emotional conflicts associated with them. By understanding and resolving core conflicts, such as those related to attachment and dependency, patients can reduce their vulnerability to future panic episodes (Keefe et al., 2019).
Resources for Working with Panic Attacks and Panic Disorder
Psychology Tools provides a variety of resources for therapists working with panic disorder, including:
Cognitive models and formulations for panic attacks and panic disorder.
Worksheets for cognitive restructuring and interoceptive exposure.
Handouts on understanding and managing panic symptoms.
Self-help materials for clients.
Audio exercises for relaxation and anxiety management.
References and Further Reading
Barlow, D. H. (2002). Anxiety and its disorders: The nature and treatment of anxiety and panic. Guilford Press.
Bouton, M. E., Mineka, S., & Barlow, D. H. (2001). A modern learning theory perspective on the etiology of panic disorder. Psychological Review, 108(1), 4–32.
Busch, F., & Milrod, B. (2010). Psychodynamic treatment of panic disorder. In R. A. Levy & J. S. Ablon (Eds.), Handbook of evidence-based psychodynamic psychotherapy: Bridging the gap between science and practice (pp. 29–44). Humana Press.
Clark, D. M. (1986). A cognitive approach to panic. Behaviour Research and Therapy, 24(4), 461–470.
Eifert, G. H., & Forsyth, J. P. (2005). Acceptance and commitment therapy for anxiety disorders. New Harbinger Publications.
Gorman, J. M., Kent, J. M., Sullivan, G. M., & Coplan, J. D. (2000). Neuroanatomical hypothesis of panic disorder. American Journal of Psychiatry, 157(4), 493–505.
Hettema, J. M., Neale, M. C., & Kendler, K. S. (2001). A review and meta-analysis of the genetic epidemiology of anxiety disorders. American Journal of Psychiatry, 158(10), 1568–1578.
Keefe, J. R., Chambless, D. L., Barber, J. P., & Milrod, B. L. (2019). Treatment of anxiety and mood comorbidities in cognitive-behavioral and psychodynamic therapies for panic disorder. Journal of Psychiatric Research, 114, 34-40.
Kessler, R. C., Petukhova, M., Sampson, N. A., et al. (2006). Twelve-month prevalence and severity of DSM-IV disorders. Archives of General Psychiatry, 62(6), 617–627.
Ley, R. (1985). Blood, breath, and fears: A hyperventilation theory of panic attacks and agoraphobia. Clinical Psychology Review, 5(4), 271–285.
McNally, R. J. (2002). Anxiety sensitivity and panic disorder. Biological Psychiatry, 52(10), 938–946.
Milrod, B., Leon, A. C., Busch, F., Rudden, M., Schwalberg, M., Clarkin, J., ... & Shear, M. K. (2007). A randomized controlled clinical trial of psychoanalytic psychotherapy for panic disorder. American Journal of Psychiatry, 164, 265-272.
Rabasco, A., McKay, D., Smits, J. A., Powers, M. B., Meuret, A. E., & McGrath, P. B. (2022). Psychosocial treatment for panic disorder: An umbrella review of systematic reviews and meta-analyses. Journal of Anxiety Disorders, 86, 102528.