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Panic Attacks and Panic Disorder - A Guide

Panic Attacks which happen for no apparent reason and become
recurrent lead to a mental health problem called panic Disorder

Introduction
panic disorder symptoms
The causes of panic disorder
Diagnosis
Treatment
Self-help
panic disorder complications

Introduction

Everyone experiences feelings of anxiety and panic at certain times during their lifetime. It is a perfectly natural response, particularly when you are in a dangerous or stressful situation. However, for people with panic disorder, feelings of anxiety, stress and panic occur regularly and at any time.

Anxiety states

Anxiety is a feeling of unease. The feeling of unease can range from mild to severe, and can include feelings of worry and fear. There are several different conditions that can cause severe anxiety. They include:

  • phobias: an extreme or irrational fear of an animal, object, place or situation
  • generalised anxiety disorder (GAD): a long-term condition that causes excessive anxiety and worry relating to a variety of situations
  • post-traumatic stress disorder: a condition that has psychological and physical symptoms and is caused by very frightening or distressing events

see: Anxiety



Panic attacks

A panic attack occurs when your body experiences a rush of intense psychological (mental) and physical symptoms.

You may feel an overwhelming sense of fear, apprehension and anxiety. As well as these feelings, you may also experience physical symptoms such as:

  • nausea
  • sweating
  • trembling
  • a sensation that your heart is beating irregularly (palpitations)

panic attacks can be very frightening and intense, but they are not dangerous. A panic attack will not cause you any physical harm and it is unlikely that you will be admitted to hospital if you have had a panic attack.

Is panic disorder common?

At least one person in 10 experiences occasional panic attacks, which are usually triggered by a stressful event.

The number of panic attacks that you have will depend on the severity of your condition. Some people may have one or two attacks each month, while others may have several attacks a week.

In the UK, approximately one person in 100 has panic disorder. Most people first develop the disorder when they are in their twenties. The condition is approximately twice as common in women as it is in men.

If you have panic disorder, it may affect your ability to drive. It is your legal obligation to inform the Driver and Vehicle Licensing Agency (DVLA) about a medical condition that could have an impact on your driving ability.

Regardless of the reason for their heroin habit, abusers of the drug should know that there are a number of heroin addiction treatment options available to them.

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Panic disorder symptoms

panic attacks can be very frightening and distressing. Symptoms tend to occur very suddenly, without warning and often for no apparent reason.

As well as overwhelming feelings of anxiety, a panic attack can also cause the following symptoms:

  • a sensation that your heart is beating irregularly (palpitations)
  • sweating
  • trembling
  • hot flushes
  • chills
  • shortness of breath
  • a choking sensation
  • chest pain
  • nausea
  • dizziness
  • feeling faint
  • numbness, or pins and needles
  • dry mouth
  • a need to go to the toilet
  • ringing in your ears
  • a feeling of dread, or a fear of dying
  • a churning stomach
  • a tingling sensation in fingers
  • shivering
  • shaking

physical symptoms of a panic attack are unpleasant, and they can also be accompanied by thoughts of fear and terror. For this reason, people with panic disorder start to fear the next attack, which creates a cycle of living in 'fear of fear' and adds to the sense of panic.

Sometimes, the symptoms of a panic attack can be so intense they can make you feel like you are having a heart attack.

However, it is important to be aware that symptoms such as a racing heartbeat, or shortness of breath, will not result in you having a heart attack. Also, although a panic attack can often be frightening, it will not cause you any physical harm. people who have had panic disorder for some time usually learn to recognise this 'heart attack sensation', and become more aware of how to control their symptoms.

The symptoms of a panic attack usually peak within 10 minutes, with most attacks lasting for between 5 and 20 minutes. Some panic attacks have been reported to have lasted up to an hour. However, it is likely that the reason for this is due to one attack occurring straight after another, or high levels of anxiety being felt after the first attack.

Recurrence

people with panic disorder have panic attacks on a recurring basis. Some people have panic attacks once or twice a month, while others have attacks several times a week.

people with panic disorder also tend to have ongoing and constant feelings of worry and anxiety. The panic attacks that are associated with panic disorder can be very unpredictable. If you have panic disorder, you may feel stressed and worried about when your next attack will be.

Depersonalisation and panic attacks

During a panic attack your symptoms can feel so intense and out of your control that you may feel detached from the situation, your body and your surroundings. It can almost feel as if you are an observer, making the situation seem very unreal.

This sense of detachment is known as depersonalisation. Being detached from the situation does not provide any relief, or make a panic attack less frightening. Instead, it often makes the experience more confusing and disorientating.

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The causes of panic disorder

As with many mental health conditions, the exact cause of panic disorder is not fully understood. It is thought that panic disorder is probably caused by a combination of physical and psychological factors. Some of these factors are outlined below.

Traumatic life experiences

A trauma, such as bereavement, can sometimes trigger feelings of panic and anxiety. These feelings may be obvious soon after the event, or they may be triggered unexpectedly years later.

Genetic link

Having a close family member with panic disorder may increase your risk of developing the condition. However, the precise nature of the risk is not yet known.

Neurotransmitters

Neurotransmitters are chemicals that occur naturally in the brain. It is thought that if you have an imbalance of these chemicals, it may increase your risk of developing conditions such as panic disorder.

Fight or flight reflex

Some researchers believe that panic disorder is closely associated with your body's natural 'fight or flight’ reflex. The fight or flight reflex is your body's way of protecting you from stressful and dangerous situations.In dangerous situations, anxiety and fear cause your body to release hormones, such as adrenalin, and your breathing and heart rate are increased. This is your body’s natural way of preparing itself for a dangerous or stressful situation.

In people with panic disorder, researchers believe that the fight or flight reflex may be triggered abnormally. In such cases, the body’s normal fight or flight response to excitement, fear or stress may be exaggerated, resulting in a panic attack.

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Diagnosising Panic Disorder

panic attacks

Everyone who has panic disorder will experience panic attacks. However, not everyone who experiences panic attacks is diagnosed with panic disorder.

Some people have panic attacks in response to specific situations. For example, they may have a phobia of enclosed spaces (claustrophobia) and have a panic attack when faced with an enclosed space.

Whereas most people with phobias only experience panic attacks when faced with whatever triggers their fear, the panic attacks of people with panic disorder are usually triggered without warning. For people with panic disorder, a panic attack often seems to occur for no obvious reason.

Therefore, a diagnosis of panic disorder will only be made if you experience recurrent and unexpected panic attacks and if these attacks are also followed by at least one month of continuous worry or concern about having further attacks.

Seeing your GP

Your Gp will ask you to describe the symptoms that you have been experiencing. They will also ask you how often your symptoms appear, and in what situations they occur. It is very important that you tell your Gp about how you have been feeling and how your symptoms have affected you.

It can sometimes be difficult to talk to someone else about your feelings, emotions and personal life. However, you should try not to feel anxious or embarrassed. Your Gp needs to gain a good understanding of your symptoms so that they can make the correct diagnosis and recommend the most appropriate treatment for your individual situation.

Physical examination

Your Gp may want to carry out a physical examination to look for signs of any physical conditions that could be causing your symptoms. For example, an overactive thyroid gland can sometimes cause similar symptoms to a panic attack. By ruling out any underlying medical conditions, your Gp will be able to make the correct diagnosis.

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Treating Panic Disorder

The main aim of treatment for panic disorder is to reduce the number of panic attacks that you have, and to help ease the severity of your symptoms.

The two main types of treatment for panic disorder are:

  • psychological therapy
  • medication

Depending on your individual circumstances, you may require either one of these treatment types, or a combination of the two. If you are offered psychological therapy, it will probably be in the form of cognitive behavioral therapy (CBT). If this type of treatment does not work, medication may be recommended.

Before you begin any form of treatment, your Gp will discuss all of your options with you, outlining the advantages of each type of treatment, while also making you aware of any possible risks or side effects.

Different treatments will suit different people so you may need to try a variety of treatments at first. This is because no single treatment is best for everyone, and the treatment that is recommended for you will depend on your general health and the severity of your condition, as well as your personal preferences.
It is important for you to understand what your treatment will involve. If you do not understand something that your Gp has told you, make sure that you ask them to explain it to you in more detail.

Cognitive behavioural therapy (CBT)

psychological therapy has proven long-term benefits, and it is the recommended form of treatment for panic disorder. If you have psychological therapy for panic disorder, it will usually be in the form of cognitive behavioural therapy (CBT).

Cognitive behavioural therapy (CBT) is thought to be one of the most effective forms of treatment for panic disorder. CBT is a psychological treatment, and will involve you having weekly sessions where you talk to a therapist.

For example, the therapist may talk to you about the way you react when you have a panic attack, and what you think about when you are experiencing an attack.

Once you and your therapist have identified any negative thoughts and beliefs, you can work on replacing them with more realistic and balanced ones. Your therapist can also teach you ways of changing your behaviour, which should make it easier for you to deal with future panic attacks. For example, they may be able to show you breathing techniques that can be used to help keep you calm during the stress of a panic attack.

The National Institute for Health and Clinical Excellence (NICE) recommend a total of seven to 14 hours of CBT, completed within a period of four months. Your treatment will usually involve having a one to two hour session, once a week.
NICE also recommend that in certain situations a shorter programme of CBT may be appropriate. This shorter programme can involve a reduced number of hours of CBT with 'homework' being set between sessions so that you can practice what has been achieved after each session.

During your course of CBT, you should visit your Gp regularly so that they can assess your progress and see how you are doing.

Help Sources

Support groups, such as Anxiety UK and Triumph Over phobia UK, will be able to provide you with useful information and advice about how to effectively manage your panic disorder, and they are also a good way of meeting other people who have similar experiences of the condition.
panic attacks can sometimes be frightening and isolating, so it can be helpful to know that other people are experiencing the same feelings and emotions as you.

Support groups often involve face-to-face meetings where you can talk about your problems and difficulties with others. Many support groups can also provide support and guidance over the telephone or in writing. Ask your Gp about support groups for panic disorder in your local area.

Medication for panic Attacks:

Antidepressants

Antidepressants are often associated with depression, but they can also be used to treat a number of other psychological conditions.

Antidepressants can take between two to four weeks before they become effective. It is therefore important that you continue to take antidepressant medication, even if you feel that it is not working. You should only ever stop taking prescribed medication if your Gp specifically advises you to do so.

The types of antidepressants that are recommended to treat panic disorder are:

  • selective serotonin reuptake inhibitors (SSRIs)
  • tricyclic antidepressants

When starting a new type of medication, it is important that you are regularly assessed by your Gp at two, four, six and 12 week intervals. This gives you the opportunity to discuss any issues that you have with your medication, and enables your Gp to asses which treatment is most effective and whether you want to consider trying a different type of medication.

Selective serotonin reuptake inhibitors (SSRIs)

Selective serotonin reuptake inhibitors (SSRIs) are a type of antidepressant that work by increasing the level of a chemical in your brain called serotonin.

SSRIs are the most commonly prescribed form of antidepressant for the treatment of panic disorder. They are usually started at a low dose before gradually being increased as your body adjusts to the medicine.

Common side effects of SSRIs include:
  • nausea
  • headaches
  • low sex drive
  • blurred vision
  • diarrhoea or constipation
  • dizziness
  • dry mouth
  • loss of appetite
  • sweating
  • feeling agitated
  • insomnia (being unable to sleep)
  • abdominal pain

When you first start taking SSRIs, your feelings of anxiety and panic may seem to get worse. In the majority of cases, this is only temporary and you will usually find that your symptoms start to return to normal levels within a few days of taking the medicine.

However, you should speak to your Gp if you feel that your symptoms have got worse and that they are not showing signs of returning to normal levels after a few days.
After you start to take a SSRI, you should visit your Gp after two, four, six, and 12 weeks so that they can check on your progress and see whether you are responding to the medicine. Not everyone responds well to antidepressant medicines, so it is important that your progress is carefully monitored.
If your Gp feels it is necessary, you may require regular blood tests, or blood pressure checks, when taking antidepressant medication. If after 12 weeks of taking the medication you do not show any signs of improvement, your Gp may prescribe an alternative SSRI for you to see if it has any effect.

The length of time that you will have to take a SSRI for will vary depending on how well you respond to the treatment. Even if you feel that your panic disorder has been successfully treated, it is likely that you will need to keep taking the medication for at least six to 12 months.

If you stop taking your SSRI medication before this time, the risk of your symptoms recurring once you stop taking the medication may be increased. Some people may have to take SSRIs for longer than six to 12 months.

When you and your Gp decide that it is appropriate for you to stop taking SSRIs, you will gradually be weaned off them by slowly reducing your dosage. As with antidepressants, you should never stop taking your medication unless your Gp specifically advises you to.

Stopping your medication straight away without being weaned off, or without seeking advice from your Gp, may result in withdrawal symptoms such as:

  • dizziness
  • numbness and tingling
  • nausea and vomiting
  • headache
  • anxiety
  • sleep disturbances
  • sweating

These symptoms can also occur if you miss a dose of medication, or if your dose is reduced. The symptoms are usually mild, but they can be severe if the medication is stopped suddenly.

For some people, this means having to take SSRIs on a long-term basis. For others, a course of cognitive behavioural therapy can help to reduce the risk of their symptoms recurring.

Contact you Gp if your side effects become troublesome and do not ease.

Tricyclic antidepressants

If SSRIs do not help to improve your symptoms after a 12 week course, or if they are not suitable, your Gp may try prescribing a different type of antidepressant.

Tricyclic antidepressants work in a similar way to SSRIs. They regulate the levels of certain chemicals in your brain (noradrenaline and serotonin), which has a positive affect on your feelings and mood.

The two tricyclic antidepressants that are often prescribed to treat panic disorder are:

  • imipramine
  • clomipramine

Tricyclic antidepressants are not addictive.

SSRIs are usually prescribed before tricyclic antidepressants because they have fewer side effects. However, common side effects of tricyclic antidepressants include:

  • constipation
  • difficulty urinating
  • blurred vision
  • dry mouth
  • weight gain or weight loss
  • drowsiness
  • sweating
  • lightheadedness
  • skin rash

The side effects should ease after seven to ten days as your body begins to get used to the medication. However, contact you Gp if they become troublesome and do not ease.

Beta-blockers

Beta-blockers are a type of medication that can be used to control the symptoms of anxiety, such as sweating and trembling.

Beta-blockers work by slowing down your heart rate and the force of your heart. This reduces the pressure at which the blood is pumped out of your heart and around your body.

Common side effects of beta-blockers include:

  • weakness
  • dizziness
  • cold hands
  • fatigue

Beta-blockers are generally not recommended for people with asthma or diabetes because they may make the symptoms of these conditions worse.

Beta-blockers can also interact with other medicines, causing possible adverse side effects. Therefore, you should check with your Gp or pharmacist before taking other medicines in combination with beta-blockers.

You should not stop taking beta-blockers suddenly without first consulting your Gp. Stopping this medication suddenly will lead to side effects, such as a rise in blood pressure or an angina attack.

Mental Health professional

If CBT, medication, or attending a support group do not help to improve your symptoms of panic disorder, you may have to be referred to a mental health professional.

A mental health specialist will carry out an overall re-assessment of your condition. They will ask you about your previous treatment and how effective you found it. They may also ask you about things in your life that may be affecting your condition, or how much support you get from family and friends.

The specialist will be able to devise a treatment plan for you, which will aim to effectively treat your symptoms.
The type of mental health specialist that you will be referred to will depend on your individual situation. For example, you may be referred to:

  • a psychiatrist - a trained medical doctor who specialises in mental health; a psychiatrist is one of the only mental health specialists who is able to prescribe medication.
  • clinical psychologists - are trained in the scientific study of human behaviour and mental processes, and focus solely on the assessment and treatment of mental health conditions; a clinical psychologist will help you to find ways of effectively managing your anxiety and your panic attacks.

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Self-help

There are several self-help techniques that you can use to help treat the symptoms of panic disorder yourself. Some of these techniques are listed below.

Stay where you are

If possible, you should stay where you are during a panic attack. The panic attack could last up to an hour, so you may need to pull over and park where it is safe to do so if you are driving. Do not rush to a place of safety.

Focus

During a panic attack, remind yourself that the frightening thoughts and sensations are a sign of panic and will eventually pass. During a panic attack it is important for you to focus on something that is non-threatening and visible, such as the time passing on your watch, or items in a supermarket.

Slow deep breathing

While you are having a panic attack, try to focus on your breathing. Your feelings of panic and anxiety can get worse if you breathe too quickly. Try to focus on slow deep breathing while counting slowly to three on each breath in and out.

Challenge your fear

During a panic attack, try to notice what it is you fear and challenge it. You can achieve this by constantly reminding yourself that what you fear is not real and that it will pass in a few minutes.

Creative visualisation

During a panic attack, lots of things can go through your mind. Some people think about disaster, or even death. Instead of letting your imagination focus on these negative thoughts, try to concentrate on positive images.

Think of a place or a situation that makes you feel peaceful, relaxed or at ease. Once you know have this image in your mind, try to focus your attention on it. It should help to distract you from the situation, and it may also help ease your symptoms.

Thinking positively can be challenging, particularly if you have got used to thinking negatively over a long period of time. Creative visualisation is a technique that will need practice, but you may gradually notice positive changes in the way that you think about yourself and others.

Do not fight an attack

Fighting a panic attack can often make the experience worse. Trying to resist the attack and finding that you are unable to can increase your sense of anxiety and panic.

Instead, during a panic attack, reassure yourself by accepting that although it may seem embarrassing, and your symptoms may be difficult to deal with, your attack is not life-threatening. Focus on the fact that your attack will have an end and try your best to let it pass.

Relaxation

If you have panic disorder, you may feel constantly stressed and anxious, particularly about when your next panic attack may be. Learning to relax can help to relieve some of this stress and tension, and may also help you to deal more effectively with your panic attacks when they occur.

Some people find that complementary therapies, such as massage and aromatherapy, help them to relax. Others find activities such as yoga, or pilates, helpful. You can also practise breathing and relaxation techniques, which you can use during a panic attack to help ease your symptoms.

Exercise

Regular exercise, particularly aerobic exercise, will help you to combat stress and release tension. It can also encourage your brain to release the chemical serotonin, which can help to improve your mood.

You should be aiming to do a minimum of 30 minutes of vigorous exercise, at least five days a week. Vigorous exercise should make you feel out of breath and tired, although not to the point where it is unbearable. Going for a brisk walk, or walking up hill, are both examples of vigorous exercise.

However, if you have not exercised before, or for a long time, you should visit your Gp for a fitness assessment before starting a new exercise programme.

See the Live Well section about Fitness for more information and advice about the benefits of regular exercise and how it can improve your health.

Diet

Unstable levels of blood sugar can contribute to the symptoms of a panic attack. Therefore, you should maintain a healthy, balanced diet, eat regularly and avoid eating sugary food and drinks. Avoid caffeine, alcohol and smoking because they can contribute to panic attacks.

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Panic disorder complications

panic disorder is a treatable condition. However, in order to make a full recovery, it is very important that you seek medical help as soon as possible. This is because treatment for panic disorder is much more effective if it is given at an early stage.

If left undiagnosed and untreated, panic disorder can become a very debilitating and isolating illness. It can also increase your risk of developing other psychological conditions.

Agoraphobia and other phobias

Agoraphobia is a fear of open spaces. If you have agoraphobia, leaving home, entering public places and travelling alone can cause you intense anxiety. Many people who have agoraphobia avoid everyday activities because of their phobia.

Agoraphobia is one of the conditions that can develop alongside panic disorder. people with panic disorder can develop agoraphobia because of their fear of having a panic attack in a public place.

You may worry that a panic attack in a public place will be embarrassing, or that you will have difficulty getting help if you need it. You may also worry about public places that you would have difficulty leaving (such as a train) if you were to have a panic attack.

If you have agoraphobia, it is likely that you will find it difficult to leave the house, particularly if you are not with a trusted family member or a friend.

If you have panic disorder, you may also develop other fears and phobias, which can often seem irrational. For example, you may start to worry that a particular object or action that triggers your attacks, and so become fearful of those things.

Children

panic disorder is more common in adolescents (teenagers) than in younger children.

panic attacks can be particularly debilitating for children and young people. A severe case of panic disorder may affect their development and learning. The fear of having a panic attack may stop children from going to school and engaging in a social life. They may also find it difficult to concentrate on their schoolwork.

Diagnosing panic disorder in children is usually a case of taking a detailed medical history and carrying out a thorough physical examination in order to rule out any physical causes for the symptoms that your child is experiencing. Screening for other anxiety disorders may also be needed in order to determine what is causing your child's panic attacks.

panic attacks in children are often dramatic events, including screaming and weeping and an increased breathing rate (hyperventilation). If your child displays the signs and symptoms of panic disorder over a prolonged period of time, your Gp may refer them to a specialist where they will be given a further assessment and treatment.

If it is recommended, your child may be given a course of psychotherapy, such as cognitive behavioural therapy (CBT).

Drug and alcohol misuse

Some studies have shown that conditions that cause intense anxiety, such as panic disorder, can also increase your risk of developing an alcohol or drug problem.

The side effects or withdrawal symptoms of both recreational (illegal) and prescribed (legal) drugs can increase the symptoms of anxiety.

Examples of legal drugs are:

  • caffeine
  • alcohol
  • cigarettes

Examples of illegal drugs are:

  • cannabis
  • cocaine
  • heroin

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