Panic Disorder. Johns Hopkins Medicine. (n.d.). https://www.hopkinsmedicine.org/health/conditions-and-diseases/panic-disorder. 

Panic Disorder Johns Hopkins 

Mayo Foundation for Medical Education and Research. (2018, May 4). Panic attacks and panic disorder. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/panic-attacks/symptoms-causes/syc-20376021#:~:text=A%20panic%20attack%20is%20a,heart%20attack%20or%20even%20dying. 

Panic attacks and disorder, Mayo Clinic

- Factors increasing anxiety
- Protective factors against anxiety

Areas impact between COVID and Anxiety/Panic Disorders

-  Sweating, trembling, shortness of breath or a feeling of choking
-  A pounding heart or rapid heart rate, and feelings of dread.
- Abdominal cramping, nausea, chest pain, headache, dizziness, numbness, tingling sensation. 
- Feeling of unreality or detachment. 
- Fear of loss of control or death.
-  Such attacks often happen suddenly, without warning
-  People who experience panic attacks often become fearful about when the next episode will occur, which can cause them to change or restrict their normal activities.

Signs of a Panic Attack

Though anxiety attacks and panic attacks are usually considered to be the same, the causes of these attacks differ. An anxiety attack is typically a result of a perceived threat or known cause. Anxiety attacks follow a  period of excessive worry, and apparent symptoms of anxiety, while panic attacks can happen out of the blue. 

Anxiety Attacks

Reference for Anxiety Sensitivity Theory

Anxiety sensitivity theory is the notion that panic disorder is partially caused by the inclination to interpret mental and physical signs of anxiety and stress as a catastrophic occurrence.  

Anxiety Sensitivity Theory 

Reference for The Prevalence of Panic Attacks

Every year, around 11% of the American population report experiencing at least one panic attack. Almost 2% to 3% of individuals in the United States suffer from panic disorder.

The Prevalence of Panic Attacks

Reference for Treatments for Panic Disorder

Treatment options for panic disorder are:
* Psychotherapy. 
* Medications.
* A combination of psychotherapy and medications.

Treatment options for panic disorder depend on the patient’s history, preference, and the severity of the disorder.

Treatments for Panic Disorder

A panic attack is an episode of intense anxiety that is marked by physical symptoms such as a racing heart, sweating, and choking sensations. These symptoms can be so severe that they can invoke the fear of dying, losing control, or going crazy.

Panic Attack

The locus coeruleus is a region located in the brainstem that serves as the brain's primary source of norepinephrine. This neurotransmitter is responsible for activating the body's fight-or-flight response. Research indicates a strong link between this area and anxiety, as its activation is associated with feelings of fear and anxiety. Studies involving nonhuman primates have demonstrated that direct stimulation of the locus coeruleus can induce panic-like symptoms, suggesting its potential role in panic disorder.

Locus Coeruleus

Which of these people are most likely to have a panic disorder?

To be diagnosed with panic disorder, an individual must experience recurrent and unexpected panic attacks. This must be followed by at least one month of persistent concern about having more attacks, worry about the consequences of the attacks (e.g., losing control), or significant, self-defeating changes in behavior aimed at avoiding future attacks.

Diagnostic Criteria for Panic Disorder

A diagnosis of panic disorder is only appropriate if the panic attacks are not a direct physiological result of substance use, a medical condition, or another mental disorder. These potential causes must be ruled out before confirming a panic disorder diagnosis.

Exclusion Criteria for Panic Disorder

A panic attack is formally defined as an abrupt surge of intense fear or discomfort that reaches its peak within ten minutes. The experience is characterized by symptoms such as an accelerated heart rate, sweating, trembling, sensations of choking, hot flashes or chills, dizziness, and intense fears of dying or losing control.

Definition of a Panic Attack

Panic disorder is often characterized as a 'fear of fear' because the experience of a panic attack is so terrifying that individuals develop an intense fear of having another one. This secondary fear leads them to become preoccupied with avoiding future attacks, often by modifying their behavior and avoiding situations they associate with panic.

Panic Disorder as 'Fear of Fear'

Panic attacks, in isolation, are not classified as a mental disorder. They are relatively common occurrences. In contrast, panic disorder is a diagnosable mental health condition characterized by recurrent, unexpected attacks and persistent fear about them, and it is significantly less common in the population.

Distinction Between Panic Attacks and Panic Disorder

Panic disorder affects a smaller portion of the population compared to isolated panic attacks. Throughout their lifetime, an estimated 4.7% of Americans meet the diagnostic criteria for the disorder.

Lifetime Prevalence of Panic Disorder

A common complication of panic disorder is the development of agoraphobia. This secondary condition is characterized by the fear and subsequent avoidance of situations or places where escape could be difficult or help might be unavailable in the event of a panic attack.

Link Between Panic Disorder and Agoraphobia

Individuals diagnosed with panic disorder often have at least one other co-occurring mental health condition. Among the most common comorbid diagnoses are other anxiety disorders and major depressive disorder.

Comorbidity in Panic Disorder

The development of panic disorder has a significant genetic component, with family and twin studies estimating its heritability at approximately 43%. This genetic predisposition is evidenced by the fact that children whose parents have panic disorder are at an increased risk of developing the condition themselves. However, the specific genes and their functions that contribute to this risk are not yet fully understood.

Genetic Factors in Panic Disorder

One prominent neurobiological theory posits that panic disorder may stem from abnormal activity of the neurotransmitter norepinephrine within the locus coeruleus. This theory is based on findings that the locus coeruleus, a major source of norepinephrine, is involved in the body's fight-or-flight response and that its stimulation can produce panic-like symptoms.

Neurobiological Theory of Panic Disorder

This theory posits that panic attacks can be learned responses acquired through classical conditioning. It suggests that subtle bodily sensations, which resemble those experienced during an initial frightening event, can become conditioned stimuli that subsequently trigger a panic attack as a conditioned response.

Conditioning Theory of Panic Disorder

Cognitive theories propose that panic disorder is driven by a tendency to misinterpret ordinary bodily sensations in a catastrophic way. According to this model, these fearful interpretations of harmless physical changes initiate a vicious cycle of escalating fear and anxiety, which triggers more physical symptoms and ultimately culminates in a panic attack.

Cognitive Theory of Panic Disorder

This disorder is hallmarked by the experience of multiple, unexpected panic attacks. These attacks are often associated with intense fear that occurs quickly. Generally, this diagnosis is applied if you have had four or more panic attacks, and fear their reocurrence. Having one panic attack, is not a panic disorder. Worry over panic attacks and avoidance of situations, places, etc. that are associated with panic attacks can lead to further problems. 

Recurrent panic attacks may show temporal lobe abnormalities. Those who suffer from panic disorder typically have lower temporal lobe volumes. These attacks can occur unexpectedly or by a trigger. 



Trinity College (CT)

Michigan State University

Arizona State University

University of Rochester

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Columbia University

List of Other Recognized Anxiety Disorders

The DSM-5-TR separates anxiety disorders into the following specific disorders:
-	Separation Anxiety Disorder
-	Selective Mutism
-	Specific Phobia
-	Social Anxiety Disorder
-	Panic Disorder
-	Panic Attack Specifier
-	Agoraphobia
-	Generalized Anxiety Disorder (GAD)
-	Substance / Medication-Induced Anxiety Disorder
-	Anxiety Disorder Due to Another Medical Condition
-	Other Specified Anxiety Disorder
-	Unspecified Anxiety Disorder


[DSM-5-TR] List of Anxiety Disorders

The major types of anxiety disorders include generalized anxiety disorder, panic disorder, specific phobia, social anxiety disorder, separation anxiety disorder, and selective mutism.

Major Types of Anxiety Disorders

Breedlove, S. & Watson, N. (2017). Behavioral neuroscience, eighth edition. Oxford University Press.

Behavioral Neuroscience 8th Edition

NIMH. (2022). Anxiety Disorders. National Institute of Mental Health. Retrieved March 12, 2022, from https://www.nimh.nih.gov/health/topics/anxiety-disorders 

Panic Disorder Reference

Spielman, R. M., Jenkins, W. J., & Lovett, M. D. (2020, April 22). Psychology (2nd ed.). OpenStax. https://openstax.org/books/psychology-2e/pages/1-introduction

OpenStax Psychology (2nd ed.) Textbook

Generalized Anxiety Disorder (GAD) is characterized by a persistent and relatively continuous state of excessive, uncontrollable, and often pointless worry and apprehension. Individuals with this disorder typically worry about routine, everyday matters, such as health, finances, or the safety of family members, without any justified reason. For a diagnosis, this diffuse worrying must occur more days than not for a period of at least six months, not be attributable to another disorder, and be accompanied by at least three of the following symptoms: restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep difficulties.

Generalized Anxiety Disorder

Panic Disorder

The term 'phobia' originates from the Greek word for fear. A phobic disorder is defined by an intense, persistent, and irrational fear of a particular object, activity, or situation. This overwhelming fear compels the individual to actively avoid the source of their phobia. Exposure to the phobic stimulus results in significant distress and dysfunction, even when the person intellectually understands that their fear is excessive. Phobic disorders are generally categorized into three types: specific phobias, agoraphobia, and social phobia.

Phobic Disorder

Hoarding disorder is characterized by a persistent difficulty in discarding or parting with possessions, regardless of their actual value. This behavior frequently results in the accumulation of items that clutter and congest the individual's living area.

Hoarding Disorder

Post-traumatic Stress Disorder (PTSD) is a condition where an individual experiences a collection of persistent symptoms following a traumatic or profoundly stressful event, such as combat, sexual assault, or a natural disaster. For a diagnosis, these symptoms must last for at least one month. The traumatic event can be witnessed firsthand or secondhand. Historically, PTSD was referred to by terms like 'shell shock' and 'combat neurosis' due to its frequent association with war, but it is now recognized as affecting a wider population.

Post-traumatic Stress Disorder (PTSD)

https://books.google.co.in/books?hl=en&lr=&id=AbYwDwAAQBAJ&oi=fnd&pg=PA2&dq=hypochondria&ots=wBYJuZQSsU&sig=teQPxyaj2KUQ0DsgOF1f8rEyrlQ&redir_esc=y#v=onepage&q=hypochondria&f=false

Hypochondriasis: Illness Anxiety Disorder and Somatic Symptom Disorder

Hypochondriasis, commonly known as hypochondria was considered a disorder where an individual believes that they have illnesses or symptoms of diseases, even when they did not. It caused anxiety and distress for patients, and potentially impeded their day-to-day functioning. However, in the DSM-V (Diagnostic and Statistical Manual of Mental Disorders), hypochondria itself was declassified as a separate disorder and instead was considered a symptom or manifestation that occurred in two different disorders. Certain characteristic features of hypochondriasis were classified under Illness Anxiety Disorder and more severe manifestations under Somatic Symptom Disorder. These disorders are both largely characterized by the preoccupation over certain undiagnosed or unexplained symptoms that persist in the individual. 

Hypochondriasis 

References  for Associations between Hoarding Disorder and  Obsessive Compulsive Disorder

Obsessive-compulsive disorder (OCD) is characterized by the presence of obsessions and/or compulsions. Obsessions are defined as intrusive and unwanted thoughts, mental images, fears, sensations, or urges. Compulsions are repetitive behaviors or mental acts that an individual feels driven to perform, often in response to an obsession. These cycles of obsessions and compulsions are typically distressing, time-consuming, and can significantly disrupt a person's daily activities.

Obsessive-Compulsive Disorder (OCD)

Separation anxiety in children seems intense or prolonged and interferes with school or other daily activities. It can also includes panic attacks. Most frequently separation anxiety disorder is linked to the child's anxiety about his or her parents, but it could relate to another close caregiver.

Less common separation anxiety disorder can occur in teenagers and adults, causing significant problems leaving home or going to work.

Separation Anxiety Disorder

A severe anxiety disorder, where a person is unable to speak in certain social situations, for example with classmates or distant relatives. Usually, selective mutism starts during childhood, if left untreated, it can continue to adulthood. Individuals with selective mutism are not choosing to not speak but are unable to speak. The expectation to talk to certain people triggers a freeze response with feelings of panic making talking impossible. 



Selective Mutism 

Social anxiety disorder (SAD) affects about 4% of the worldwide population and is slightly more common in women. Also known as social phobia, it is defined as a persistent,and potentially debilitating fear of meeting new people, being watched, or criticized by others. Some with social anxiety may attempt to avoid anxiety-triggering situations by self-isolating or cancelling plans. It is a profound fear of the judgement of peers, particularly public humiliation. It is NOT shyness or introversion but can sprout from childhood shyness. In a social sense, social anxiety is not just feeling nervous or shy in certain social situations like starting a new job or the first day of school. Social anxiety disorder is a disorder that interferes with everyday life and relationships due to fearing situations where you can be embarrassed or viewed negatively and intense fear of situations where a person with SAD expects the worst. 

Social Anxiety Disorder (Social Phobia)

Derived from the Greek for 'fear of the marketplace,' agoraphobia is an anxiety disorder defined by intense fear and avoidance of situations where escape might be difficult or help unavailable if panic symptoms arise. Such situations often include using public transportation, being in open areas like parking lots, enclosed spaces like stores, crowded places, or being outside the home alone.

Agoraphobia

Very Well Mind. Retrieved June 30th, 2023 from https://www.verywellmind.com/

Very Well Mind

This disorder refers to an increased amount of anxiety that stems from alcohol, drug, or medication usage. This diagnosis would go beyond the anxiousness or panic during intoxication/withdrawal. The anxiety causes distress and impariment.

Substance / Medication-Induced Anxiety Disorder

When someone's physical health condition is the direct cause for symptoms of anxiety or panic.

Anxiety Disorder Due to Another Medical Condition

MSD Manual, Professional Version. Retrieved July 2nd, 2023 from https://www.msdmanuals.com/professional

MSD Manual, Professional Version

A specific phobia, formerly known as a simple phobia, is an anxiety disorder characterized by excessive, distressing, and persistent fear or anxiety centered on a specific object or situation. Individuals with a specific phobia often recognize that their level of fear is irrational, yet they may go to great lengths to avoid the phobic stimulus. The anxiety and avoidance behaviors associated with the phobia are typically disruptive to the person's daily life and functioning.

Specific Phobia

For the past eight months, David has experienced a near-constant state of worry. He feels anxious about his performance at work, the health of his parents, and his financial situation, despite there being no specific or immediate threats in these areas. He reports feeling restless, easily fatigued, and has significant muscle tension in his neck and shoulders. His condition is best described by which of the following?

Social anxiety disorder, which was previously known as social phobia, is defined by an intense and persistent fear of social situations where an individual might face negative judgment from others. This anxiety leads to the avoidance of such situations.

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