Internet Mental Health

PANIC DISORDER





Internet Mental Health Quality of Life Scale (Client Version)

Internet Mental Health Quality of Life Scale (Therapist Version)

Big 5 Factors Of Mental Illness And Code For This Disorder
(The "6th Big Factor" of Mental Health, "Physical Health", Is Coded Abnormal or Red)

  • Sudden attacks of intense fear or discomfort which occur in the absence of real danger.

  • At least 1 month of fear about having another attack.

  • Not due to a medical or substance use disorder.

Prediction

    After 10 years, 30% are well, 45% are better, 25% are same or worse.

Problems

Occupational-Economic Problems:

  • Causes significant impairment in academic, occupational and/or social functioning.

  • Panic attacks at school or work may not be noticed by others.

  • Much of the impairment comes not from the panic attacks themselves, but what happens between attacks. People stop going to the places where they had panic attacks. It is this avoidance behavior that becomes the most disabling symptom of panic disorder.

  • In severe panic disorder, the individual's avoidance behavior may reach the point where they become housebound and can no longer leave the security of their home because of their fear of having another panic attack (agoraphobia).

  • Anxiety Disorders account for 14.6% of the disability caused by mental illness worldwide.

Confusion (Impaired Intellect):

  • Cognitive impairment during a panic attack ("thinking paralyzed by fear", "feels like I'm going crazy").

Detached (Detachment):

  • Social withdrawal when severe (becomes housebound).

Negative Emotions (Negative Emotion):

    Recurrent unexpected panic attacks:
    A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur:

  • Palpitations, pounding heart, or accelerated heart rate.

  • Sweating.

  • Trembling or shaking.

  • Sensations of shortness of breath or smothering.

  • Feelings of choking.

  • Chest pain or discomfort.

  • Nausea or abdominal distress.

  • Feeling dizzy, unsteady, light-headed, or faint.

  • Chills or heat sensations.

  • Paresthesias (numbness or tingling sensations).

  • Derealization (feelings of unreality) or depersonalization (being detached from oneself).

  • Fear of losing control or "going crazy".

  • Fear of dying.

    • Note: 10% to 65% also have major depressive disorder.

Medical:

  • Panic attacks are not due to a medical illness; however these individuals often have dizziness, cardiac arrhythmias, asthma, chronic obstructive pulmonary disease, and irritable bowel syndrome

  • Subjectively, panic attacks feel like something is medically wrong (e.g., "I'm having a heart attack, stroke or I'm dying")

  • Physiological vulnerability to panic attacks: these individuals are abnormally sensitive to sodium lactate infusion or carbon dioxide inhalation (which triggers their panic attacks)

Fear, Generalized Anxiety, Phobia, Panic, Obsession, and Compulsion

Fearful avoidance is part of our instinctual "flight" response to adversity.

Our ancestors learned to fear dangerous things (e.g., snakes), and this harm avoidance saved their lives.

However, fear can spiral out of control. For example, an individual can develop a phobia to snakes in which the fear becomes excessive. The individual may then panic if exposed to snakes. This phobia can develop into an obsession in which the individual spends much of the time thinking about snakes, and how to avoid them. The obsession can develop into a compulsion in which the individual spends much of the time doing superstitious, compulsive, ritual behaviors aimed at avoiding snakes.

There are stages in the escalation of fear:

  • Normal Fear:
    Fear is normal if it is in proportion to the actual danger posed by the specific object or situation, and this fear doesn't cause significant distress or disability.

  • Generalized Anxiety:
    Fear can become excessive, and generalized with excessive anxiety and worry about a number of objects or situations. This anxiety is often associated with avoidance of the feared objects or situations and irritability. Generalized anxiety disorder occurs in 15%-30% of individuals with panic disorder.

  • Phobia:
    Fear can become excessive, and specifically attached to specific objects or situations (e.g., fear of flying). This phobic fear is out of proportion to the actual danger posed by these feared objects or situations, and the individual desperately tries to avoid whatever triggers the phobia. This phobic fear causes significant distress or disability. The majority of individuals with panic disorder show signs of anxiety and agoraphobia before the onset of panic disorder. Individuals with panic disorder also have an increased risk of developing social anxiety disorder (15%-30%) and specific phobia (2%-20%).

  • Panic:
    Phobic individuals can develop a full-blown panic attack if exposed to whatever triggers their phobia. In panic disorder, individuals experience panic attacks that occur spontaneously, and that are not triggered by any phobic stimulus.

  • Obsession:
    If the individual develops persistent, unwanted thoughts about the phobia; this is defined as an obsession. An obsession is an unwanted, recurrent, persistent, fear-provoking intrusive thought. Individuals with panic disorder usually don't develop obsessions.

  • Compulsion:
    A compulsion is a ritual an individual develops to combat an obsession. Thus compulsions are fear-relieving avoidance behaviors. The individual feels driven to perform these compulsions. Individuals with panic disorder usually don't develop compulsions.

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Click Here For Free Diagnosis

Limitations of Self-Diagnosis

Self-diagnosis of this disorder is often inaccurate. Accurate diagnosis of this disorder requires assessment by a qualified practitioner trained in psychiatric diagnosis and evidence-based treatment.

However, if no such professional is available, our free computerized diagnosis is usually accurate when completed by an informant who knows the patient well. Computerized diagnosis is less accurate when done by patients (because they often lack insight).

Example Of Our Computer Generated Diagnostic Assessment

Panic Disorder without Agoraphobia 300.01

This diagnosis is based on the following findings:
  • Recurrent and unexpected panic attacks developed abruptly and peaked within 10 minutes (still present)
  • Worried for at least 1 month about having panic attacks (still present)
  • Panic attacks caused palpitations, pounding heart, or accelerated heart rate (still present)
  • Panic attacks caused chest pain or discomfort (still present)
  • Panic attacks caused derealization or depersonalization (still present)
  • Panic attacks caused fear of losing control or going crazy (still present)
  • Panic attacks caused fear of dying (still present)
  • Panic attacks were not due to a general medical condition
  • Panic attacks were not due to substance use or other treatment
  • Panic attacks were not accompanied by agoraphobia
  • Panic attacks were not due to another mental disorder

TREATMENT GOALS:

  • Goal: prevent worry about having future panic attacks.
    If this problem persists: She will start to fear and avoid the situations that were previously associated with her panic attacks.

  • Goal: prevent panic attacks from causing palpitations, pounding heart, or accelerated heart rate.
    If this problem persists: She may develop the belief that she has undetected, life-threatening heart disease.

  • Goal: prevent panic attacks from causing chest pain or discomfort.
    If this problem persists: She may develop the belief that she has undetected, life-threatening heart disease.

  • Goal: prevent panic attacks from causing derealization or depersonalization.
    If this problem persists: This could seriously demoralize her.

  • Goal: prevent panic attacks from causing fear of losing control or going crazy.
    If this problem persists: This fear of losing control or going crazy could seriously demoralize her.

  • Goal: prevent panic attacks from causing fear of dying.
    If this problem persists: This could lead to both chronic debilitating anxiety and excessive visits to health care facilities.


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Panic Disorder F41.0 - ICD10 Description, World Health Organization

The essential feature of panic disorder is recurrent attacks of severe anxiety (panic), which are not restricted to any particular situation or set of circumstances and are therefore unpredictable. As with other anxiety disorders, the dominant symptoms include sudden onset of palpitations, chest pain, choking sensations, dizziness, and feelings of unreality (depersonalization or derealization). There is often also a secondary fear of dying, losing control, or going mad. Panic disorder should not be given as the main diagnosis if the patient has a depressive disorder at the time the attacks start; in these circumstances the panic attacks are probably secondary to depression.
Panic Disorder - Diagnostic Criteria, American Psychiatric Association

An individual diagnosed with panic disorder needs to meet all of the following criteria:

  • Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur: (Note: The abrupt surge can occur from a calm state or an anxious state.)

    • Palpitations, pounding heart, or accelerated heart rate.

    • Sweating.

    • Trembling or shaking.

    • Sensations of shortness of breath or smothering.

    • Feelings of choking.

    • Chest pain or discomfort.

    • Nausea or abdominal distress.

    • Feeling dizzy, unsteady, light-headed, or faint.

    • Chills or heat sensations.

    • Paresthesias (numbness or tingling sensations).

    • Derealization (feelings of unreality) or depersonalization (being detached from oneself).

    • Fear of losing control or "going crazy".

    • Fear of dying.

      • Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms.

  • At least one of the attacks has been followed by 1 month (or more) of one or both of the following:

    • Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, "going crazy").

    • A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations).

  • The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary disorders).

  • The disturbance is not better explained by another mental disorder (e.g., the panic attacks do not occur only in response to feared social situations, as in social anxiety disorder; in response to circumscribed phobic objects or situatioins, as in specific phobia; in response to obsessions, as in obsessive-compulsive disorder; in response to reminders of traumatic events, as in posttraumati stress disorder; or in response to separation from attachment figures, as in separation anxiety disorder).


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Diagnostic Features

Panic Disorder is a condition characterized by 2 or more unexpected Panic Attacks followed by at least 1 month of persistent concern about having another Panic Attack. A Panic Attack is a discrete period of intense apprehension, fearfulness, or terror which occurs in the absence of real danger. The Panic Attack has a sudden onset and builds to a peak rapidly (usually in 10 minutes or less) and is often accompanied by a sense of impending doom and an urge to escape. During these attacks, symptoms such as shortness of breath, palpitations, chest pain or discomfort, choking or smothering sensations, and fear of "going crazy" or losing control are present. These Panic Attacks are not due to a general medical condition (e.g., hyperthyroidism) or due to the direct physiological effects of a substance (e.g., Caffeine Intoxication). The anxiety that is characteristic of a Panic Attack can be differentiated from generalized anxiety by its discrete, almost paroxysmal, nature and its typically greater severity. In Panic Disorder With Agoraphobia there is marked avoidance of panic-provoking situations.

Complications

Individuals with Panic Disorder often anticipate a catastrophic outcome from a mild physical symptom or medication side effect. Such individuals are also much less tolerant of medication side effects and generally need continued reassurance in order to take medication. The belief that they have an undetected life-threatening illness may lead to both chronic debilitating anxiety and excessive visits to health care facilities. Demoralization is a common consequence, with many individuals becoming discouraged, ashamed, and unhappy about the difficulties of carrying out their normal routines. These individuals may frequently be absent from work or school for doctor and emergency-room visits, which can lead to unemployment or dropping out of school.

Psychological Comorbidity

The majority of individuals with panic disorder show signs of anxiety and agoraphobia before the onset of panic disorder. From 10% to 65% of individuals with panic disorder at sometime in their life also have major depressive disorder. Often individuals may treat their panic disorder with alcohol or medications, and thus may develop alcoholism or drug addiction as a consequence. Social anxiety disorder (social phobia) and generalized anxiety disorder have been reported in 15%-30% of individuals with panic disorder, specific phobia in 2%-20%, obsessive-compulsive disorder in up to 10%, and posttraumatic stress disorder in 2%-10%. Hypochondriasis commonly occurs in panic disorder.

Medical Comorbidity

Individuals with panic disorder often have dizziness, cardiac arrhythmias, asthma, chronic obstructive pulmonary disease, and irritable bowel syndrome. The nature of these associations (e.g., cause-and-effect) remains unclear. The association between panic disorder and mitral valve prolapse or thyroid disease is controversial.

Associated Laboratory Findings

No laboratory test has been found to be diagnostic of this disorder. Some individuals with panic disorder show signs of compensated respiratory alkalosis.

Prevalence

The 12-month prevalence rate for this disorder in America and Europe is 2% to 3%. Panic disorder is diagnosed in approximately 10% of individuals referred for mental health consultation, and in approximately 60% of individuals in cardiology clinics. Approximately one-third to one-half of individuals diagnosed with panic disorder in community samples also have agoraphobia (i.e., fear leaving home alone). Women are 2 times more likely to develop panic disorder than men.

Course

This disorder may begin at any age, but most individuals develop this disorder between adolescence and the mid-30s. A small number of cases begin in childhood, and onset after age 45 is unusual (but can occur). The median age at onset is 20-24 years. The usual course, if untreated, is chronic but waxing and waning. Some individuals have a chronic, episodic course (with episodic outbreaks with years of remission in between). Others have continuous severe symptomatology. Although agoraphobia may develop at any point, its onset is usually within the first year of panic disorder.

Outcome

The agoraphobia accompanying panic disorder may become chronic regardless of the continued presence or absence of panic attacks. Anxiety Disorder Clinics report that, at 6-10 years posttreatment, about 30% of their patients are well, 40%-50% are improved but symptomatic, and the remaining 20%-30% have symptoms that are the same or worse.

Familial Pattern

Twin studies indicate a genetic contribution to the development of panic disorder. If the age at onset of the panic disorder is before 20, first-degree relatives have been found to be up to 20 times more likely to have Panic Disorder. However, as many as one-half to three-quarters of individuals with Panic Disorder do not have an affected first-degree biological relative.

Effective Therapies

Cognitive behavioral therapy (CBT), benzodiazepines and antidepressants (SSRI + SNRI) are very effective as treatments for this disorder. Addiction-prone individuals should not be treated with benzodiazepines.

Ineffective therapies

Vitamins and dietary supplements are ineffective for this disorder.

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Treatment Guidelines

Treatment

Treatment - Summarized From Royal Australian & New Zealand College Of Psychiatrists Treatment Guideline (2003)

Psychological Treatment

All effective psychological treatments for Anxiety Disorders incorporate one or more of the following: (1) cognitive exposure (mentally facing the fear), (2) behavioral exposure (physically facing the fear), (3) correcting maladaptive coping (eliminating the negative thinking and superstitious behaviors associated with the fear), and (4) reducing stressors (reducing health/economic/occupational/social stressors using a problem-solving approach).

  • Facing the Fear of Having a Panic Attack:
    • Education about the symptoms, the disorder, and the specific role of fear of bodily sensations
    • Exposure to the physical symptoms that comprise and cue panic attacks
    • Hyperventilation control
    • Overcoming distress intolerance (by mindfulness training)
    • Cognitive therapy to change maladaptive thought processes

  • Real-Life Exposure to Avoided Situations:
    This involves gradual exposure to fear-provoking situations that the person has avoided because of previous panic attacks there. Repeated exposure to these fear-provoking situations helps the person realise that the feared situation is no longer associated with having another panic attack.

Pharmalogical Treatment

The strongest evidence supports the effectiveness of tricyclic antidepressants, SSRI antidepressants and high potency benzodiazepines. Benzodiazepine (BZD) use carries with it the high risk of creating dependency. The efficacy of maintenance medication to prevent relapse has not been firmly established. Unlike psychological treatment, relapse on discontinuation of pharmalogical treatment is common.

How Do The Effective Treatments Compare?

  • The majority of patients show a positive response to cognitive behavioral therapy (CBT) or medication
  • A positive response typically occurs within 6 weeks (response to benzodiazepines occurs considerably faster) but additional time may be required to stabilise the response
  • If there is an inadequate response after an adequate trial of a first line treatment, switch to another evidence-based treatment
  • The number needed to treat to get one person panic free is 3 for CBT and 6 for medication
  • CBT has greater durability than pharmacotherapy
  • Dropout rates for CBT are lower than for pharmacotherapy
  • Combining BZDs with CBT reduces treatment efficacy when compared to CBT alone
  • CBT has been shown to reduce relapse following discontinuation of benzodiazepines

Issues in Managing Pharmacological Treatment

  • Medications, especially benzodiazepines, should be discontinued gradually (this may be difficult because of dependence and may provoke relapse or even rebound panic)
  • When used alone, antidepressants should be continued for at least 6 months following symptom remission, and longer if full remission does not occur
  • Some clinicians advocate stopping medication only when the patient is in a stable life situation.
  • Longer use of medication may reduce the risk of relapse following discontinuation
  • For patients with repeated episodes of panic disorder, long-term use of medication use may be indicated
  • People with panic disorder often require low beginning doses and slow titration of medication

Treatment - Summarized From National Institute for Health and Clinical Excellence (NICE) Treatment Guideline (2011)

Treatment Of Panic Disorder

    Offer Treatment in Primary Care

      The recommended treatment options have an evidence base: psychological therapy, medication, and self-help have all been shown to be effective. The choice of treatment will be a consequence of the assessment process and shared decision-making.

      There may be instances when the most effective intervention is not available (for example, CBT) or is not the treatment option chosen by the person. In these cases, the healthcare professional will need to consider, after discussion with the person, whether it is acceptable to offer one of the other recommended treatments. If the preferred treatment option is currently unavailable, the healthcare professional will also have to consider whether it is likely to become available within a useful timeframe.

    General

      Benzodiazepines are associated with a less good outcome in the long term and should not be prescribed for the treatment of individuals with panic disorder.

      Sedating antihistamines or antipsychotics should not be prescribed for the treatment of panic disorder.

      In the care of individuals with panic disorder, any of the following types of intervention should be offered and the preference of the person should be taken into account. The interventions that have evidence for the longest duration of effect, in descending order, are:

      • Psychological therapy (see recommendations below)
      • Pharmacological therapy (antidepressant medication) (see recommendations below)
      • Self-help (see recommendations below)

      The treatment option of choice should be available promptly.

      There are positive advantages of services based in primary care (for example, lower rates of people who do not attend) and these services are often preferred by people.

    Psychological Interventions

      CBT should be used.

      CBT should be delivered only by suitably trained and supervised people who can demonstrate that they adhere closely to empirically grounded treatment protocols.

      CBT in the optimal range of duration (7–14 hours in total) should be offered.

      For most people, CBT should take the form of weekly sessions of 1–2 hours and should be completed within a maximum of 4 months of commencement.

      Briefer CBT should be supplemented with appropriate focused information and tasks.

      Where briefer CBT is used, it should be around 7 hours and designed to integrate with structured self-help materials.

      For a few people, more intensive CBT over a very short period of time might be appropriate.

    Pharmacological Interventions – Antidepressant Medication

      Antidepressants should be the only pharmacological intervention used in the longer term management of panic disorder. The two classes of antidepressants that have an evidence base for effectiveness are the SSRIs and tricyclic antidepressants (TCAs).

      The following must be taken into account when deciding which medication to offer:

      • The age of the person
      • Previous treatment response
      • Risks
        • The likelihood of accidental overdose by the person being treated and by other family members if appropriate
        • The likelihood of deliberate self-harm, by overdose or otherwise (the highest risk is with TCAs)
      • Tolerability
      • The possibility of interactions with concomitant medication (consult Appendix 1 of the 'British National Formulary')
      • The preference of the person being treated
      • Cost, where equal effectiveness is demonstrated

      All people who are prescribed antidepressants should be informed, at the time that treatment is initiated, of potential side effects (including transient increase in anxiety at the start of treatment) and of the risk of discontinuation/withdrawal symptoms if the treatment is stopped abruptly or in some instances if a dose is missed or, occasionally, on reducing the dose of the drug.

      People started on antidepressants should be informed about the delay in onset of effect, the time course of treatment, the need to take medication as prescribed, and possible discontinuation/withdrawal symptoms. Written information appropriate to the person's needs should be made available.

      Unless otherwise indicated, an SSRI licensed for panic disorder should be offered.

      If an SSRI is not suitable or there is no improvement after a 12-week course and if a further medication is appropriate, imipramine or clomipramine may be considered.

      When prescribing an antidepressant, the healthcare professional should consider the following.

      • Side effects on the initiation of antidepressants may be minimised by starting at a low dose and increasing the dose slowly until a satisfactory therapeutic response is achieved.
      • In some instances, doses at the upper end of the indicated dose range may be necessary and should be offered if needed.
      • Long-term treatment may be necessary for some people and should be offered if needed.
      • If the person is showing improvement on treatment with an antidepressant, the medication should be continued for at least 6 months after the optimal dose is reached, after which the dose can be tapered.

      If there is no improvement after a 12-week course, an antidepressant from the alternative class (if another medication is appropriate) or another form of therapy (see recommendation above under "General") should be offered.

      People should be advised to take their medication as prescribed. This may be particularly important with short half-life medication in order to avoid discontinuation/withdrawal symptoms.

      Stopping antidepressants abruptly can cause discontinuation/withdrawal symptoms. To minimise the risk of discontinuation/withdrawal symptoms when stopping antidepressants, the dose should be reduced gradually over an extended period of time.

      All people prescribed antidepressants should be informed that, although the drugs are not associated with tolerance and craving, discontinuation/withdrawal symptoms may occur on stopping or missing doses or, occasionally, on reducing the dose of the drug. These symptoms are usually mild and self-limiting but occasionally can be severe, particularly if the drug is stopped abruptly.

      Healthcare professionals should inform people that the most commonly experienced discontinuation/withdrawal symptoms are dizziness, numbness and tingling, gastrointestinal disturbances (particularly nausea and vomiting), headache, sweating, anxiety, and sleep disturbances.

      Healthcare professionals should inform people that they should seek advice from their medical practitioner if they experience significant discontinuation/withdrawal symptoms.

      If discontinuation/withdrawal symptoms are mild, the practitioner should reassure the person and monitor symptoms. If severe symptoms are experienced after discontinuing an antidepressant, the practitioner should consider reintroducing it (or prescribing another from the same class that has a longer half-life) and gradually reducing the dose while monitoring symptoms.

    Self-Help

      Bibliotherapy based on CBT principles should be offered.

      Information about support groups, where they are available, should be offered. (Support groups may provide face-to-face meetings, telephone conference support groups [which can be based on CBT principles], or additional information on all aspects of anxiety disorders plus other sources of help.)

      The benefits of exercise as part of good general health should be discussed with all people with panic disorder as appropriate.

Review and Offer Alternative Treatment if Appropriate

    If, after a course of treatment, the clinician and the person with panic disorder agree that there has been no improvement with one type of intervention, the person should be reassessed and consideration given to trying one of the other types of intervention.

    Review and Offer Referral from Primary Care if Appropriate

    In most instances, if there have been two interventions provided (any combination of psychological intervention, medication, or bibliotherapy) and the person still has significant symptoms, then referral to specialist mental health services should be offered.

Care in Specialist Mental Health Services

    Specialist mental health services should conduct a thorough, holistic reassessment of the individual, their environment and social circumstances. This reassessment should include evaluation of:

    • Previous treatments, including effectiveness and concordance
    • Any substance use, including nicotine, alcohol, caffeine, and recreational drugs
    • Comorbidities
    • Day-to-day functioning
    • Social networks
    • Continuing chronic stressors
    • The role of agoraphobic and other avoidant symptoms

    A comprehensive risk assessment should be undertaken and an appropriate risk management plan developed.

    To undertake these evaluations, and to develop and share a full formulation, more than one session may be required and should be available.

    Care and management should be based on the individual's circumstances and shared decisions made. Options include:

    • Treatment of co-morbid conditions
    • CBT with an experienced therapist if not offered already, including home-based CBT if attendance at clinic is difficult
    • Structured problem solving
    • Full exploration of pharmaco-therapy
    • Day support to relieve carers and family members
    • Referral for advice, assessment, or management to tertiary centres

    There should be accurate and effective communication between all healthcare professionals involved in the care of any person with panic disorder, and particularly between primary care clinicians (general practitioner and teams) and secondary care clinicians (community mental health teams) if there are existing physical health conditions that also require active management.

Monitoring and Follow-up for Individuals with Panic Disorder

    Psychological Interventions

      There should be a process within each practice to assess the progress of a person undergoing CBT. The nature of that process should be determined on a case-by-case basis.

    Pharmacological Interventions

      When a new medication is started, the efficacy and side-effects should be reviewed within 2 weeks of starting treatment and again at 4, 6, and 12 weeks. Follow the summary of product characteristics with respect to all other monitoring required.

      At the end of 12 weeks, an assessment of the effectiveness of the treatment should be made, and a decision made as to whether to continue or consider an alternative intervention.

      If medication is to be continued beyond 12 weeks, the individual should be reviewed at 8- to 12-week intervals, depending on clinical progress and individual circumstances.

    Self-Help

      Individuals receiving self-help interventions should be offered contact with primary healthcare professionals, so that progress can be monitored and alternative interventions considered if appropriate. The frequency of such contact should be determined on a case-by-case basis, but is likely to be between every 4 and 8 weeks.

Outcome Measures

    Short, self-completed questionnaires (such as the panic subscale of the agoraphobic mobility inventory for individuals with panic disorder) should be used to monitor outcomes wherever possible.

Potential Harms

    • The main adverse events associated with antidepressants are cardiovascular symptoms, bleeding, gastrointestinal symptoms, sexual dysfunction, weight change, and suicidal ideation and behavior.
    • There was consistent evidence that selective serotonin reuptake inhibitors (SSRIs) were associated with an increased risk of gastrointestinal bleeding particularly in elderly people. Although such events were relatively rare, the guideline development group considered this was still important to take into account when considering prescribing an SSRI. In addition, there was evidence that antidepressant use was associated with an increased probability of suicidal behavior in participants under 25 years of age.
    • All SSRIs have been implicated in the development of serotonin syndrome, a potentially life threatening complication.
    • Serotonin noradrenaline reuptake inhibitors (SNRIs) carry a risk of increasing blood pressure.

Contraindications

    Benzodiazepines are not recommended because of the potential for the development of tolerance and dependence in a condition where treatment may need to be given for several months but are still in relatively wide use.


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Self-Help Resources For Panic Disorder






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    "In physical science a first essential step in the direction of learning any subject is to find principles of numerical reckoning and practicable methods for measuring some quality connected with it. I often say that when you can measure what you are speaking about and express it in numbers you know something about it; but when you cannot measure it, when you cannot express it in numbers, your knowledge is of a meagre and unsatisfactory kind: it may be the beginning of knowledge, but you have scarcely, in your thoughts, advanced to the stage of science, whatever the matter may be."

    Lord Kelvin (1824 – 1907)

  • The best summary on bad research is given by Laura Arnold in this TEDx lecture. If you read nothing else about research, you owe it to yourself to watch this short video - it is excellent!

  • Canadian researchers who commit scientific fraud are protected by privacy laws: There are criminals in every community - even in the scientific research community (especially if a lot of money is at stake). Criminal researchers can hide their fraud behind outdated privacy laws.

  • The power of asking "what if?"

  • The active placebo effect: 2300 years ago, the Greek Stoic philosophers taught that it is not the objective event, but our subjective judgment about the event, that determines our behavior. The active placebo effect bears witness to this ancient wisdom.

  • Criteria For High Quality Research Studies

    • It is troubling that a recent study found that two-thirds of important psychological research studies couldn't be replicated. High quality research must meet the following criteria:

    • Randomized Controlled Trial:
      Ask: Was the trial randomized? Was the randomization procedure described and was it appropriate? The best research design is to have research subjects randomly assigned to an experimental or control group. It is essential that confounding factors be controlled for by having a control group or comparator condition (no intervention, placebo, care as usual etc.).

    • Representative Sample:
      Ask: Do the research subjects represent a normal cross-section of the population being studied? Many psychological research studies using university students are flawed because their subjects are not representative of the normal population since they are all W.E.I.R.D. (White, Educated, Intelligent, Rich, and living in a Democracy).

    • Single Blind Trial:
      Ask: Was the treatment allocation concealed? It is essential that the research subjects are kept "blind" as to whether they are in the experimental or control group (in order to control for any placebo effects).

    • Double Blind Trial (Better Than Single Blind Trial):
      Ask: Were blind outcome assessments conducted? In a double blind study, neither the research subjects nor the outcome assessors know if the research subject is in the experimental or control group. This controls for both the placebo effect and assessor bias.

    • Baseline Comparability:
      Ask: Were groups similar at baseline on prognostic indicators? The experimental and control groups must be shown to be comparable at the beginning of the study.

    • Confounding Factors:
      Ask: Were there factors, that weren't controlled for, that could have seriously distorted the study's results? For example, research studies on the effectiveness of mindfulness cognitive therapy in preventing depressive relapse forgot to control for whether the research subjects were also simultaneously receiving antidepressant medication or other psychological treatments for depression.

    • Intervention Integrity:
      Ask: Was the research study protocal strictly followed? The research subjects must be shown to be compliant (e.g., taking their pills, attending therapy) and the therapists must be shown to be reliably delivering the intervention (e.g., staying on the research protocol).

    • Statistical analysis:
      Ask: Was a statistical power calculation described? The study should discuss its statistical power analysis; that is whether the study size is large enough to statistically detect a difference between the experimental and control group (should it occur) and usually this requires at least 50 research subjects in the study.

      Ask: Are the results both statistically significant and clinically significant? Many medical research findings are statistically significant (with a p-value <0.05), but they are not clinically significant because the difference between the experimental and control groups is too small to be clinically relevant.

      For example, the effect of a new drug may be found to be 2% better than placebo. Statistically (if the sample size was large enough) this 2% difference could be statistically significant (with a p-value <0.05). However, clinicians would say that this 2% difference is not clinically significant (i.e., that it was too small to really make any difference).

      Statistically, the best way to test for clinical significance is to test for effect size (i.e., the size of the difference between two groups rather than confounding this with statistical probability).

      When the outcome of interest is a dichotomous variable, the commonly used measures of effect size include the odds ratio (OR), the relative risk (RR), and the risk difference (RD).

      When the outcome is a continuous variable, then the effect size is commonly represented as either the mean difference (MD) or the standardised mean difference (SMD) .

      The MD is the difference in the means of the treatment group and the control group, while the SMD is the MD divided by the standard deviation (SD), derived from either or both of the groups. Depending on how this SD is calculated, the SMD has several versions such, as Cohen's d, Glass's Δ, and Hedges' g.

        Clinical Significance: With Standard Mean Difference, the general rule of thumb is that a score of 0 to 0.25 indicates small to no effect, 0.25-0.50 a mild benefit, 0.5-1 a moderate to large benefit, and above 1.0 a huge benefit. It is a convention that a SMD of 0.5 or larger is a standard threshold for clinically meaningful benefit.

      The statistical summary should report what percentage of the total variance of the dependent variable (e.g., outcome) can be explained by the independent variable (e.g., intervention).

      In clinical studies, the study should report the number needed to treat for an additional beneficial outcome (NNTB), and the number needed to treat for an additional harmful outcome (NNTH).

        Number Needed To Benefit (NNTB): This is defined as the number of patients that need to be treated for one of them to benefit compared with a control in a clinical trial. (It is defined as the inverse of the absolute risk reduction.) Note: Statistically, the NNTB depends on which control group is used for comparison - e.g., active treatment vs. placebo treatment, or active treatment vs. no treatment.

        Number Needed To Harm (NNTH): This is defined as the number of patients that need to be treated for one of them to be harmed compared with a control in a clinical trial. (It is defined as the inverse of the absolute increase in risk of harm.)

        Tomlinson found “an NNTB of 5 or less was probably associated with a meaningful health benefit,” while “an NNTB of 15 or more was quite certain to be associated with at most a small net health benefit.”

      Ask: Does the researcher accept full responsibility for the study's statistical analysis? The researcher should not just hand over the study's raw data to a corporation (that may have $1,000 million invested in the study) to do the statistical analysis.

    • Completeness of follow-up data:
      Ask: Was the number of withdrawals or dropouts in each group mentioned, and were reasons given for these withdrawals or dropouts? Less than 20% of the research subjects should drop out of the study. The intervention effect should persist over an adequate length of time.

    • Handling of missing data:
      Ask: Was the statistical analysis conducted on the intention-to-treat sample? There must be use of intention-to-treat analysis (as opposed to a completers-only analysis). In this way, all of the research subjects that started the study are included in the final statistical analysis. A completers-only analysis would disregard those research subjects that dropped out.

    • Replication of Findings:
      Ask: Can other researchers replicate this study's results? The research study's methodology should be clearly described so that the study can be easily replicated. The researcher's raw data should be available to other researchers to review (in order to detect errors or fraud).

    • Fraud:
      Ask: Is there a suspicion of fraud? In a research study, examine the independent and dependent variables that are always measured as a positive whole number (e.g., a variable measured on a 5-point Likert-type scale ranging from "1 = definitely false to 5 = definitely true" etc.). For each of these variables, look at their sample size (n), mean (M) and standard deviation (SD) before they undergo statistical analysis. There is a high suspicion of fraud in a study's statistics:

      • If the M is mathematically impossible (online calculator): This is one of the easiest ways to mathematically detect fraud. The mean (M) is defined as "the sum (Sum) of the values of each observation divided by the total number (n) of observations". So: M = Sum/n. Thus: (Sum) = (M) multiplied by (n). We know that, if a variable is always measured as a positive whole number, the sum of these observations always has to be a whole number. For these variables to test for fraud: calculate (M) multiplied by (n). This calculates the Sum which MUST be a positive whole number. If the calculated Sum isn't a positive whole number; the reported mean (M) is mathematically impossible - thus the researcher either cooked the data or made a mistake. A recent study of 260 research papers published in highly reputable psychological journals found that 1 in 2 of these research papers reported at least one impossible value, and 1 in 5 of these research papers reported multiple impossible values. When the authors of the 21 worst offending research papers were asked for their raw data (so that its reliability could be checked) - 57% angrily refused. Yet such release of raw data to other researchers is required by most scientific journals. (Here is an example of a research paper filled with mathematically impossible means.)

      • If the SD is mathematically impossible (online calculator): When researchers fraudulently "cook" their data, they may accidently give their data a mean and standard deviation that is mathematically impossible.

      • If the SD/M is very small (i.e., the variable's standard deviation is very small compared to the mean suggesting data smoothing).

      • If the SD's are almost identical (i.e., the variables have different means but almost identical standard deviations).

      • If the 4th digit of the values of the variables aren't uniformly distributed - since each should occur 10% of the time (Benford's Law).

      • If the researcher is legally prevented from publishing negative findings about a drug or therapy because that would violate the "nondisclosure of trade secrets" clause in the research contract (i.e., it is a "trade secret" that the drug or therapy is ineffective - hence this can not be "disclosed"). Approximately half of all registered clinical trials fail to publish their results.

      • If the researcher refuses to release his raw data to fellow researchers (so that they can check its validity). In order to be published in most scientific journals, a researcher must promise to share his raw data with fellow researchers. Thus a researcher's refusal to do so is almost a sure indicator of fraud.

      • If the research study's data contradicts the study's own conclusions - surprisingly, this often occurs.

  • Calling Bullshit In The Age of Big Data - "Bullshit is language, statistical figures, data graphics, and other forms of presentation intended to persuade by impressing and overwhelming a reader or listener, with a blatant disregard for truth and logical coherence." Reading the syllabus of this university course should be required reading for every student of mental health. This syllabus is absolutely fantastic!

  • Statistical Methods in Psychology Journals: Guidelines and Explanations - American Psychologist 1999

  • Not All Scientific Studies Are Created Equal - video

  • The efficacy of psychological, educational, and behavioral treatment

  • Estimating the reproducibility of psychological science

  • Psychologists grapple with validity of research

  • Industry sponsorship and research outcome (Review) - Cochrane Library

  • 'We've been deceived': Many clinical trial results are never published - (text and video)

  • Junk science misleading doctors and researchers

  • Junk science under spotlight after controversial firm buys Canadian journals

  • Medicine with a side of mysticism: Top hospitals promote unproven therapies - Are some doctors becoming modern witchdoctors?

  • When Evidence Says No, But Doctors Say Yes


Research Topics

Panic Disorder - Latest Research (2016-2017)

Cochrane Review (The best evidence-based, standardized reviews available)

Strong evidence of effectiveness:
  • Psychotherapy combined with antidepressants for panic disorder (2009) (Psychotherapy plus antidepressant treatment were compared with each of the two individual treatments alone for panic disorder. At the end of the acute phase treatment, the combined therapy was superior to psychotherapy or antidepressant treatment alone. After termination of active treatment, the combined therapy was superior to antidepressants alone and was as effective as psychotherapy alone. Either combined therapy or psychotherapy alone may be chosen as first line treatment for panic disorder with or without agoraphobia, depending on patient preference.)

Not yet possible to draw any definite conclusions due to insufficient evidence:
  • Repetitive transcranial magnetic stimulation (rTMS) for panic disorder (2014) (Only two randomized controlled trials of rTMS were available and their sample sizes were small. The available data were insufficient for us to draw any conclusions about the efficacy of rTMS for panic disorder. Further trials with large sample sizes and adequate methodology are needed to confirm the effectiveness of rTMS for panic disorder.)

  • Psychotherapy and a benzodiazepine combined for treating panic disorder (2009) (The review established the paucity of high quality evidence investigating the efficacy of psychotherapy combined with benzodiazepines for panic disorder. Currently, there is inadequate evidence to assess the clinical effects of psychotherapy combined with benzodiazepines for patients who are diagnosed with panic disorder.)

  • Azapirones versus placebo for panic disorder in adults (2014) (The efficacy of azapirones is uncertain due to the lack of meta-analysable data for the primary outcome and low-quality evidence for secondary efficacy outcomes. A small amount of moderate-quality evidence suggested that the acceptability of azapirones for panic disorder was lower than for placebo. However, only trials of one azapirone (namely buspirone) were included in this review; this, combined with the small sample size, limits our conclusions. If further research is to be conducted, studies with larger sample sizes, with different azapirones and with less risk of bias are necessary to draw firm conclusions regarding azapirones for panic disorder.)


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Which Behavioral Dimensions Are Involved?

Research has shown that there are 5 major dimensions (the "Big 5 Factors") of personality disorders and other mental disorders. There are two free online personality tests that assess your personality in terms of the "Big 5 dimensions of personality". Although not computerized online, the Big Five Inventory (BFI) is a 44-item test often used in personality research.

This website uses these 5 major dimensions of human behavior to describe all mental disorders. (This website adds one more dimension, "Physical Health", but our discussion will focus on the first 5 major dimensions.)

These major dimensions of human behavior seem to represent the major dimensions whereby our early evolutionary ancestors chose their hunting companions or spouse. To maximize their chance for survival, our ancestors wanted companions who were agreeable, conscientious, intelligent, sociable, emotionally stable, and physically healthy.

    Which Dimensions of Human Behavior are Impaired in Panic Disorder?

    THE POSITIVE SIDE OF THE "BIG 5" PERSONALITY DIMENSIONS THE NEGATIVE SIDE OF THE "BIG 5" PERSONALITY DIMENSIONS THIS DISORDER
    Agreeableness Antagonism       Agreeableness
    Conscientiousness Disinhibition       Conscientiousness
    Intellect Decreased Intellect       Intellect
    Sociability (Extraversion) Detachment       Sociability (Extraversion)
    Emotional Stability Negative Emotion       Negative Emotion

The 5 Major Dimensions of Mental Illness

The Big 5 Factors or dimensions of mental illness each has a healthy side and an unhealthy side. Thus the Big 5 Factors are: (1) Agreeableness vs. Antagonism, (2) Conscientiousness vs. Disinhibition, (3) Intellect vs. Decreased Intellect, (4) Sociability (Extraversion) vs. Detachment (Introversion), and (5) Emotional Stability vs. Negative Emotion.

The Following Will Only Discuss The Dimensions of Mental Illness That Are Abnormal In This Disorder

The problems that are diagnostic of this disorder are highlighted in   Pink  . Other problems that are often seen in this disorder are highlighted in   Yellow  .



Treatment Goals for Individuals With Negative Emotion

EMOTIONAL STABILITY VS. NEGATIVE EMOTION
.
EMOTIONAL STABILITY
.
Description: Emotional Stability is synonymous with being calm and emotionally stable. The Emotional Stability dimension measures the behaviors that are central to the concept of COURAGE - having calm composure and endurance when confronting adversity. High emotional stability is associated with better: longevity, leadership, job [team] performance, and marital success. (This dimension appears to measure the behaviors that differentiate safety from danger.)
Descriptors: Calm, even-tempered, peaceful, confident
Language Characteristics: Pleasure talk, agreement, compliment, low verbal productivity, few repetitions, neutral content, calm, few self-references, many short silent pauses, few long silent pauses, many tentative words, few aquiescence, little exaggeration, less frustration, low concreteness.
"I am relaxed, and I handle stress well."
"I am emotionally stable, and not easily upset."
"I remain calm in tense situations."
"I rarely get irritated."
"I keep my emotions under control."
"I rarely lose my composure."
"I am not easily annoyed."
"I seldom feel blue."
"I feel comfortable with myself."
"I rarely feel depressed."
"I am not embarrassed easily."
.
NEGATIVE EMOTION
.
Description: Degree to which people experience persistent anxiety or depression and are easily upset. (This could be thought of as high threat sensitivity or low stress tolerance.)
Descriptors: Emotionally unstable, anxious, separation-insecure, depressed, self-conscious, oversensitive, vulnerable.
Language Characteristics: Problem talk, dissatisfaction, high verbal productivity, many repetitions, polarised content, stressed, many self-references, few short silent pauses, many long silent pauses, few tentative words, more aquiescence, many self references, exaggeration, frustration, high concreteness.
Research: Lower scores on Emotional Stability are associated with unhappiness, dysfunctional relationships, and mental health problems. *MRI research found that Low Emotional Stability (= Negative Emotion or Neuroticism) was associated with increased volume of brain regions associated with threat, punishment, and negative emotions.
.
* Emotional Instability:
"I get emotional easily, often for very little reason."
"I get emotional over every little thing."
"My emotions are unpredictable."
"I never know where my emotions will go from moment to moment."
"I am a highly emotional person."
"I have much stronger emotional reactions than almost everyone else."
"My emotions sometimes change for no good reason."
"I get angry easily."
"I get upset easily."
"I change my mood a lot."
"I am a person whose moods go up and down easily."
"I get easily agitated."
"I can be stirred up easily."
.
* Anxiety:
"I worry about almost everything."
"I'm always fearful or on edge about bad things that might happen."
"I always expect the worst to happen."
"I am a very anxious person."
"I get very nervous when I think about the future."
"I often worry that something bad will happen due to mistakes I made in the past."
"I am filled with doubts about things."
"I feel threatened easily."
"I am afraid of many things."
.
* Separation Insecurity:
"I fear being alone in life more than anything else."
"I can't stand being left alone, even for a few hours."
"I’d rather be in a bad relationship than be alone."
"I'll do just about anything to keep someone from abandoning me."
"I dread being without someone to love me."
.
* Submissiveness:
"I usually do what others think I should do."
"I do what other people tell me to do."
"I change what I do depending on what others want."
.
* Perseveration:
"I get stuck on one way of doing things, even when it's clear it won't work."
"I get stuck on things a lot."
"It is hard for me to shift from one activity to another."
"I get fixated on certain things and can’t stop."
"I feel compelled to go on with things even when it makes little sense to do so."
"I keep approaching things the same way, even when it isn’t working."
.
* Depressed Mood:
"I have no worth as a person."
"Everything seems pointless to me."
"I often feel like a failure."
"The world would be better off if I were dead."
"The future looks really hopeless to me."
"I often feel just miserable."
"I'm very dissatisfied with myself."
"I often feel like nothing I do really matters."
"I know I'll commit suicide sooner or later."
"I talk about suicide a lot."
"I feel guilty much of the time."
"I'm so ashamed by how I've let people down in lots of little ways."
"I am easily discouraged."
"I become overwhelmed by events."
.
("Emotional Stability vs. Negative Emotion" modified from "PID-5" by Kreuger RF, Derringer J, Markon KE, Watson D, Skodol AE and Between facets and domains: 10 aspects of the Big Five)
*MRI Research: Testing predictions from personality neuroscience. Brain structure and the big five.


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