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Panic attacks and panic disorder

What is panic disorder?

Panic disorder is defined by recurrent abrupt surges of intense fear or discomfort associated with various somatic (e.g. palpitations, sweating, trembling, chest pain, sensations of shortness of breath, nausea, dizziness, numbness etc.) and mental symptoms (e.g. derealization, depersonalization, fear of losing control or dying) without cue or trigger.

 

What are the symptoms of a panic attack?

Four or more of 13 symptoms need to have occurred to make a diagnosis of panic attack:

  • physical
    • palpitations (heart pounding), accelerated heart rate
    • sweating
    • trembling or shaking
    • shortness of breath or smothering
    • feelings of choking
    • chest pain/discomfort
    • nausea or abdominal distress
    • feeling dizzy, unsteady or faint
    • chills or flushes
    • paresthesias (numbness or tingling sensations)
  • mental
    • fear of losing control or “going crazy”
    • fear of dying

What is the difference between a panic attack and panic disorder?

Panic attacks are usually one-off experiences and far more frequent than panic disorder. Only if there are recurrent panic attacks, the diagnosis of "panic disorders" can be made.

At least one of the panic attacks has to be followed by one month of one or both of the following:

  • persistent concern/worry about additional panic attacks or their consequences (e.g. heart attacks, losing control, going crazy)
  • a consistent maladaptive change in behaviour (e.g. avoidance of exercise, unfamiliar situations)

What other disorders are often associated with panic attacks? 

There are certain mental or physical disorders that often come together with panic attacks:

  • Other anxiety disorders
    • agoraphobia
    • social anxiety disorder
    • specific phobia
  • Depression and bipolar disorder
  • Medical conditions

What are the causes of panic disorder?

  • genetics
  • temperament: anxious temperaments have been shown to be a risk factor
  • life stress: bereavement, relationship, work issues, threat, illness
  • childhood adversity: history of physical or sexual abuse and smoking increases risk of panic disorder in adult years
  • substance abuse: alcohol, recreational drugs, prescription medicine

Therapy of panic disorder

Panic disorder can be treated by psychotherapy, medication (usually drugs such as selective serotonin reuptake inhibitors (SSRI) that are used as antidepressants) or a combination of both (see picture below for an overview).

Cognitive-behavioural therapy and clinical hypnosis for panic disorder

  • Training in self-hypnosis

A training in self-hypnosis (or another relaxation method) is an essential in the therapy of anxiety. Patients suffering from anxiety disorders have symptoms of the stress or fight-and-flight response. For example, they could have symptoms such as sweating, tense muscles, fast breathing, and a fast heartbeat. One of the best ways to regain control over such bodily symptoms is self-hypnosis. This very useful tool allows the patient to relax the muscles, slow down the breathing and heartbeat, and find a calm state of mind.

  • Other self-control relaxation techniques used to control panic attacks
    • breathing techniques: slow diaphragmatic breathing is a good way to quickly relax
    • body-scan exercises: moving the awareness through the whole body, from head to toes
    • sensory awareness: shifting the focus of your awareness from inside your body to the environment (e.g. listening to the sounds, looking at the colours around you, etc.), can help to reduce panic
  • Cognitive restructuring

Catastrophic thinking is one of the core elements in panic attacks. A patient with panic disorder might misinterpret some of the symptoms of the fight-or-flight response (e.g. pounding heart, sweating, and fast breathing) as the opening act to a catastrophic event, such as a heart attack or a respiratory arrest. The task of cognitive restructuring is to challenge these interpretations by countering them with scientific explanations.

  • Relaxation on a cue

We can teach patients to relax on a cue by rehearsing this technique in hypnosis and advising the patient to self-practice after the session. For instance, if you start to think about a job interview you have to go for, press your thumb and index finger together (a way of conditioning the pressing together of the fingers with the relaxation response) and go into self-hypnosis for a short while. Or alternatively, take some calming breaths or shift your attention to the sounds, colours, and aromas around you.

  • Imaginal exposure and systematic desensitization
The patient is asked about some situations she/he feels uncomfortable, situations that have triggered or could trigger a panic attack. Then the patient rates each situation, from least to most uncomfortable and together with the therapist constructs a hierarchy. Hypnosis is induced and the therapist will ask the patient to imagine the situation ranking lowest in discomfort. In this state of deep relaxation, the therapist will go through all the anxiety-provoking situations until the patient does no longer feel any discomfort.
 
Reference: Lynn SJ and Kirsch I (2006): Essentials of Clinical Hypnosis American Psychological Association
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