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Anxiety Disorders
Panic Disorder
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Psychopathology >> Clinical Features of Anxiety Disorders - Panic Disorder >> Contents
Contents
1. Introduction to Anxiety Disorders
2. Introduction to Panic Attacks
3. Diagnosis & Epidemiology
4. Case Study
5. Aetiology
6. Treatment
10

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Psychopathology >> Clinical Features of Anxiety Disorders - Panic Disorder >> Introduction to Anxiety Disorders
1. Introduction to Anxiety Disorders (1/2)
11
Anxiety is normal…
• Anxiety is a common reaction to stress. It prevents
humans from being careless.
• Examples:
• Anxiety about your examination makes you study.
• Anxiety over her baby’s health makes a mother
care for her baby.
…however, in same situations anxiety can be abnormal
• If anxiety crosses a reasonable limit, it might become a disorder
• Examples:
• when one is so anxious that he/she has a breakdown in the
exam hall, forgetting everything
• when a mother is so anxious about her baby’s health, that she
spends day and night praying to God
Nature of Anxiety
Fear
• Fear is a basic emotion of human beings associated with
the perception of a real threatening situation and involves
the ‘fight or flight’ response activated by the sympathetic
nervous system.
• Example: If a street thug attacks you, you would feel intense
fear. Then, you would either run for dear life, or hit him back.
• Thus fear involves:
• cognition of the threatening object,
• subjective cognition of being in danger,
• physiological components like increased heart rate,
• behavioural components like running or hitting.
Anxiety
• Anxiety also involves subjective perception of threat,
physiological changes and some behavioural reaction.
• However, there is no immediate threat - you are
projecting the threatening situation in future and
reacting to it as if it is imminent. If you cannot go out of
your home because of apprehensions of an attack by a
hoodlum, it is anxiety.
• Anxiety serves an adaptive function - it prepares a person
for fight or flight if the danger really comes. But if the
person avoids the situation that in her perception may
cause the danger, and if such imagined situations are
unrealistic, then the effect becomes debilitating.

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One may distinguish between adaptive
anxiety and pathological anxiety by
assessing the realistic probability of the
occurrence of the object of anxiety and
by assessing how dysfunctional it makes
the person.

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Psychopathology >> Clinical Features of Anxiety Disorders - Panic Disorder >> Introduction to Anxiety Disorders
1. Introduction to Anxiety Disorders (2/2)
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Common Characteristics/Nature of Anxiety Disorders
• Cognition or subjective perception of danger – may be accompanied by
vivid, occasionally morbid, images of the difficulties encountered.
• Physiological Responses - through activation of sympathetic nervous
system. Usually includes dilated pupils, increased heart rate, trembling,
breathing discomfort, nausea etc.
• Behavioural Responses - usually a tendency to avoid the dreaded situation.
Except in OCD and sometimes PTSD, where repetitive behaviour is observed.
Anxiety
Disorder
Anxiety Disorder is a blanket term that covers a group of disorders characterized by
irrational fear of some thing or situation. The person is usually aware of the irrationality.
Focus of this document
1
Panic Disorder
(with or without
agoraphobia)
2
Phobic Disorders
(specific or social)
3
Generalised
Anxiety Disorder
(GAD)
4
Obsessive
Compulsive
Disorder
(OCD)
5
Post Traumatic
Stress Disorder
(PTSD)
Types of Anxiety Disorders
(DSM IV TR)

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Psychopathology >> Clinical Features of Anxiety Disorders - Panic Disorder >> Contents
Contents
1. Introduction to Anxiety Disorders
2. Introduction to Panic Attacks
3. Diagnosis & Epidemiology
4. Case Study
5. Aetiology
6. Treatment
14

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Psychopathology >> Clinical Features of Anxiety Disorders - Panic Disorder >> Introduction to Panic Attacks
2. Introduction to Panic Attacks
• Panic attacks are characterized by their unexpectedness - the symptoms develop abruptly
and usually reach its peak within 10 - 15 minutes. During such attack the victim becomes
completely overpowered by the symptoms, many of which are physiological in nature.
• Panic attack is not dangerous, but it can be truly frightening. In a number of cases patients
have been admitted for emergency cardiac care, particularly because the symptoms, mostly
physiological, mimic cardiac symptoms.
• Panic attacks can be with or without agoraphobia.
• Panic attacks with agoraphobia seem to be precipitated by attending a cinema hall, a
shopping mall, a queue, tunnels, trains, aircrafts etc., where a large number of people
congregate and escape in case of a panic attack may be difficult.
15
Panic Attack
Panic attack is an episode of irrational intense fear or apprehension that is of sudden
onset. It is accompanied by strong autonomic arousal and numerous bodily symptoms
often mimicking cardiac attack.
Agoraphobia
The word ‘agora’ is Greek for ‘public places’ or ‘assembly of people.’ Agoraphobia is the
irrational intense fear of crowded places from where escape might be difficult.

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Psychopathology >> Clinical Features of Anxiety Disorders - Panic Disorder >> Introduction to Panic Attacks
2.1. Clinical Features of a Panic Attack
Brain: Irritability, Dizziness
16
Throat: Lump
Muscles: Tension
Skin: Sweating
Blood: High BP
Intestine: Nausea, Diarrhea
Limb Extremities:
Paresthesia (pins and
needles sensation)
Windpipe: Choking sensation
Lungs: Breathlessness
Heart: Palpitation
• The typical clinical description of panic attack is
featured by intense terror, at times in the form
of fear of dying or going crazy.
• Nervousness, shaking and stress are common.
• The most prominent underlying characteristic is
the person seems to have no control on oneself.
• Sometimes one feels like the beginning of a heart
attack, as difficulty in breathing (as if one is not
getting enough air), palpitation, hyperventilation,
rapid heart bits, chest pain and choking sensation
along with profuse sweating predominate.
• Often there is a dizziness, lightheadedness,
nausea and fainting.
• One feels dissociated from reality – one almost
seems to be detached from the immediate
surroundings and drawn in a whirlpool of odd
sensations.
• Occasionally there are hot flashes or sudden
chills, burning sensation in facial and neck area,
tingling in fingers and toes (paresthesia).
• Difficulty in vision is also observed in the form of
flashing vision and tunnel vision (loss of
peripheral vision).
• The reactions are usually those associated with
activation of sympathetic nervous system.

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Psychopathology >> Clinical Features of Anxiety Disorders - Panic Disorder >> Contents
Contents
1. Introduction to Anxiety Disorders
2. Introduction to Panic Attacks
3. Diagnosis & Epidemiology
4. Case Study
5. Aetiology
6. Treatment
17

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Psychopathology >> Clinical Features of Anxiety Disorders - Panic Disorder >> Diagnosis and Epidemiology
3. Panic Disorder Diagnosis and Epidemiology
18
Diagnosis
• As per DSM IV TR a person can be diagnosed as suffering from
panic disorder if she has experienced recurrent unexpected attacks
and is persistently concerned with having another attack for at least
one month.
• She must have at least 4 of the 13 symptoms during the attack:
1. Palpitation or pounding heart
2. Sweating
3. Trembling or shaking
4. Sensation of shortness of breath or being smothered
5. Feeling of choking
6. Chest pain or discomfort
7. Nausea or abdominal distress
8. Feeling dizzy, lightheaded or faint
9. Derealisation or depersonalisation
10. Fear of losing control or going crazy
11. Fear of dying
12. Paresthesias
13. Chill or hot flushes.
Epidemiology of Panic Attacks
• Estimations of prevalence of
panic disorder and panic attacks
at some point of life ranges
between 3% to 5% of the
population.
• It is usually more common in
women.
• This gender difference may be
attributed to cultural factors, as
unrealistic fear is tolerated more
in women, but men need to
keep up a brave face.
• Thus, in different cultures with
different gender role
prescriptions, the male female
ratio may change.
• The age of onset is usually
between 15 and 24.

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Psychopathology >> Clinical Features of Anxiety Disorders - Panic Disorder >> Contents
Contents
1. Introduction to Anxiety Disorders
2. Introduction to Panic Attacks
3. Diagnosis & Epidemiology
4. Case Study
5. Aetiology
6. Treatment
19

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Psychopathology >> Clinical Features of Anxiety Disorders - Panic Disorder >> Case Study
4. Panic Disorder Case Study
• Background: Sophia is a young lady from a middle class family, studying at the University. She lives in the suburbs and
regularly takes the metro to the University. She is somewhat introvert, apparently cool and rational, and determined to
finish her education.
• Event:
− One day while waiting for the train, she had some kind of physical discomfort. However, she ignored it and boarded
the train. The train was moderately crowded and she did not get a seat. She stood in front of the seat reserved for
ladies.
− A few minutes later, she felt choked and nauseated, started sweating profusely. She was so uncomfortable that she
asked the elderly lady sitting in front of her for help. This lady immediately offered her a seat and asked her what her
problem was.
− By this time, Sophia was trembling and started crying - “I am going to die.” Other passengers gave her water to drink,
and at the next station they took her out of the train and contacted the authority.
− She was taken to a hospital and her father was informed. By the time he arrived, Sophia was feeling much better.
• Diagnosis:
− Doctors found a rapid pulse rate, but did not get anything indicating cardiac problem.
− She retrospectively reported extreme fear of being choked to death, especially as she was in an underground train
and could not jump out and run for the sunlight up on the streets.
− The experience left Sophia extremely fearful of travel by underground train. She understands that this is irrational, but
cannot face traveling by underground train again, or even crowded buses. Now she takes auto rickshaws for her
travel and has to change vehicles a number of times to reach the University.
− Her confidence has lowered considerably. Often she insists that her father accompany her.
− She has been diagnosed of panic attack with agoraphobia.
20

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Psychopathology >> Clinical Features of Anxiety Disorders - Panic Disorder >> Contents
Contents
1. Introduction to Anxiety Disorders
2. Introduction to Panic Attacks
3. Diagnosis & Epidemiology
4. Case Study
5. Aetiology
6. Treatment
21

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Psychopathology >> Clinical Features of Anxiety Disorders - Panic Disorder >> Aetiology
5. Panic Disorder Aetiology
22
Causes of Panic Disorder
1
Biological Causes
1.1
Genetic Factors
1.2
Biochemical abnormalities
in the Brain
2
Psychosocial Causes
2.1
Learning Factors
2.2
Cognitive Factors
Changes in the individual’s
perception which trigger
panic attacks.

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Psychopathology >> Clinical Features of Anxiety Disorders - Panic Disorder >> Aetiology
5.1. Biological Factors
23
1.1. Genetic Factors
• Family and twin studies indicate
that panic disorder runs in
families. Identical twins seem to
have greater possibilities of
panic disorder, while
concordance is less in fraternal
twins.
• The specific genes responsible
for panic disorder are yet to be
discovered. However, there
seems some evidence that
panic disorder and phobia may
have some genetic
commonness.
1.2. Brain and biochemical abnormalities
• Exposure to certain biochemicals causes panic attack in those who
are already suffering from panic disorder, while there may be no
impact on others. Thus, there might be definite neurobiological
differences between those with panic disorder and normal individuals.
• Some substances provoking panic are sodium lactate, carbon
dioxide, caffeine etc. However, the brain mechanisms associated with
their actions are not identical and possibly a single neurobiological
mechanism may not be responsible for all types of panic attacks.
• Some brain mechanisms implicated in panic attack are:
• Increased activity in the hippocampus and locus coeruleus, which
are responsible for monitoring external and internal stimuli and
moderate brain’s reactions to them.
• Amygdala is critically important in fear reaction, and is involved in
the ‘fear network’ of the brain. Abnormal sensitivity in this region
may cause repeated anxiety attacks.
• Increased noradrenergic activity simulates cardiac problem by
enhancing heart rate and breathing problems.
• People with panic disorder may have abnormalities in their
benzodiazepine receptors which help in anxiety reduction. The role
of GABA neurotransmitter may be important.

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The Vicious Panic Cycle
Psychopathology >> Clinical Features of Anxiety Disorders - Panic Disorder >> Aetiology
5.2.1. Learning Factors
24
Perceived
Threat
Apprehension
of panic attack
(fear of fear)
Bodily
Sensations
Interpretation
of sensations as
catastrophe
Triggering Stimulus
(external or internal)
• Learning theory views panic attacks as a learnt
phenomena – specifically as responses to
conditioned stimuli.
• Sophia’s case:
• Her first panic attack happened in the metro.
• So the situation of the train became the
conditioned stimulus, and she is afraid that
panic attack may happen again when she is in
a crowded vehicle.
• Thus, the initial learning is reinforced and
increases in vigour by reinforcements in a
cyclic pattern. This explanation is also known
as ‘fear of fear’.
• Sometimes, an internal stimulus may act as the
trigger for panic attack.
• Example: an increased heart rate may be so
associated with panic attack experiences that if
heart rate increases for any reason, panic
attack starts.
• Thus, oversensitivity to internal stimuli can also
be a cause of panic disorder. Triggering Stimulus

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Psychopathology >> Clinical Features of Anxiety Disorders - Panic Disorder >> Aetiology
5.2.2. Cognitive Factors
• The cognitive approach to panic attack focuses on the interpretation of bodily sensations and
external cues that may trigger the attack.
• While the learning approach highlights the oversensitivity to bodily cues, the cognitive approach further
affirms that a catastrophic meaning may be assigned to the bodily sensation.
− Example: racing of the heart may be attributed to a serious malfunctioning of the cardiac system,
rather than to the medicine one has taken.
• If the person is not aware of this catastrophic thought, it may fall within the arena of ‘automatic thoughts’
that non-consciously result in the attack.
• The role of interpretation is crucial here.
− This has been highlighted by experiments where the heart rate has been increased in panic disorder
patients by using drugs.
− If the person knows about the possible effects of the drug, panic attack does not take place or occurs
to a much milder degree.
• Panic disorder patients are also known to demonstrate cognitive bias toward certain experiences and
symbols.
− Example: they may be more prone to words like ‘fainting’ or ‘shortness of breath’.
− It is, however, not clear whether these biases have been generated after repeated panic attacks or
were already present before the first attack.
• But, there seems to be accumulating evidence that a special kind of cognitive orientation is present in
some people, which make them more amenable to consider certain stimuli as triggers of panic attack
more quickly than others.
25

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Psychopathology >> Clinical Features of Anxiety Disorders - Panic Disorder >> Contents
Contents
1. Introduction to Anxiety Disorders
2. Introduction to Panic Attacks
3. Diagnosis & Epidemiology
4. Case Study
5. Aetiology
6. Treatment
26

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Psychopathology >> Clinical Features of Anxiety Disorders - Panic Disorder >> Treatment
6. Panic Disorder Treatment
Panic disorder may be treated by pharmacology or psychotherapy, or a combination of both.
27
Pharmacology
• Tranquilizers from the Benzodiazepine group
of drugs (alprazolam or clonazepam) are often
used to handle panic attacks.
• These however, have the side effect of being
addictive.
• Antidepressants like Tricyclics and SSRIs
(Selective Serotonin Reuptake Inhibitors) have
also been used successfully to deal with panic
attacks.
• These drugs, particularly SSRIs do not have
the immediate calming effect like the
Benzodiazepine group of drugs
• They are relatively free from addiction and
have better result in long term treatment.
• Although extrapyramidal effects like
dryness of mouth may be occasional side
effects, these are better tolerated by most
people also.
Psychotherapy
• Relaxation techniques and breathing exercises are
useful for self management by the patient.
• These techniques include gradually relaxing the
muscles of your body, progressively from one
extremity to another, and controlling breathing so
that the internal cues of fear are regulated and under
control.
• Cognitive technique can be used to identify the
erroneous automatic thoughts and review them in the
light of reality orientation.
• Example: ask the patient to imagine the worst that
can happen to her and to judge the probability of its
occurrence in real life. Ask her to identify the
triggering cues and to dissociate them by practice
from the immediate physiological responses.
• It has been suggested that cognitive technique is
more helpful than medicine for long term
maintenance of the cure in case pf panic disorder.

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