You’ve probably seen images of or read about the Greek god, Pan. He’s that little half-goat with the iconic flute; a nature god connoting fertility and forest groves. What you probably didn’t know is that he also had a weapon: a terrifying scream. When passers-by disturbed Pan’s naps, he would unleash his blood-curdling cry, scaring them to death. Hence, a feeling of sudden terror came to be termed Panic. (Barlow, 2004)
About 3% of Americans currently suffer with panic disorder (“Facts & Statistics | Anxiety and Depression Association of America, ADAA,” n.d.), with many more enduring more occasional panic attacks. In contrast to the myth of Pan, panic attacks are not deadly, though they can feel as though they are: a fear of death is a relatively common symptom during these episodes. Other features listed in the DSM-V are palpitations, sweating, trembling, chest pain, nausea, dizziness, chills or heat sensations, paresthesias (tingling or prickling sensation), derealisation (the sense that the external world is not real) and fear of losing control. Panic disorder happens when panic attacks occur relatively frequently and unexpectedly, with the patient persistently worrying about having them and changing their behavior maladaptively (American Psychiatric Association, 2013). Panic disorder also predisposes patients to developing agoraphobia. Although agora is a Greek term for marketplace, implying a fear of public spaces, agoraphobia refers to a general avoidance of situations in which individuals fear they will have a panic attack or be unable to escape or find help (Sadock & Sadock, 2008).
In isolation, these signs and symptoms are not uncommon, and can occur in numerous other conditions. Palpitations, for example, can have a cardiac cause. It is therefore necessary, as always, to take an appropriately thorough history to rule out other serious causes of these findings. A recent systematic review grants us some insight on refining our differential: Herr et al. found that the PHQ 5-question panic subscale (available for free at phqscreeners.com) had good accuracy (LR+ = 78 and LR- = 0.20) for assessing the probability of panic disorder (Herr, Williams, Benjamin, & McDuffie, 2014).
There have been various mechanisms proposed for panic attacks over the decades. According to current cognitive-behavioral models, panic attacks are related to a misinterpretation of bodily symptoms (Ham, Waters, & Oliver, 2005). The result is a “vicious cycle” of physiological reaction to cognitions and further faulty cognitions (“Why is my chest feeling funny? Maybe this is a heart attack! Now I’m having difficulty breathing – this must be a heart attack, I’m going to die!”). Indeed, self-focus may be a key component of the cognitive-affective basis of anxiety in general (Barlow, 2004).
In summary, panic attacks are a relatively common phenomenon with a number of potential psychiatric comorbidities and sequelae. Clinicians who believe their patient may have panic disorder should obtain a thorough history and administer the panic subscale of the PHQ, available at phqscreeners.com as it has good accuracy for the diagnosis of panic disorder.
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC.
- Barlow, D. H. (2004). Anxiety and Its Disorders: The Nature and Treatment of Anxiety and Panic (2nd ed.). New York: Guilford Press.
- Facts & Statistics | Anxiety and Depression Association of America, ADAA. (n.d.). Retrieved November 05, 2014, from http://www.adaa.org/about-adaa/press-room/facts-statistics
- Ham, P., Waters, D. B., & Oliver, M. N. (2005). Treatment of panic disorder. American Family Physician, 71(4), 733–9. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/15742911
- Herr, N. R., Williams, J. W., Benjamin, S., & McDuffie, J. (2014). Does this patient have generalized anxiety or panic disorder?: The Rational Clinical Examination systematic review. JAMA, 312(1), 78–84. doi:10.1001/jama.2014.5950
- Sadock, B. J., & Sadock, V. A. (2008). Kaplan & Sadock’s Concise Textbook of Clinical Psychiatry. Philadelphia: Lippincott Williams & Wilkins.
Chris Roberts, ND, has an anxiety-centered practice at Mahaya Forest Hill Integrative Health in Toronto. He is the course coordinator of Cliinical Medicine at the Canadian College of Naturopathic Medicine and a supervisor at the Robert Schad Naturopathic Clinic in Toronto.
Dr. Roberts’s interest in mental health intensified during his undergraduate studies in linguistics and human biology when he began volunteering at a call-in distress line. Anxiety became his specific practice focus while he was completing his clinical residency at the Canadian College of Naturopathic Medicine.