Dr. Goldberg
PC15
April 13, 2007
Panic Attacks in Young Adults (18-29) Right before I left for college I experienced the single most terrifying thing that has ever happened to me. This experience and the fear of it happening again stalked me day and night. It is something that has stayed with me and that I deal with and fear on a daily basis. It wasn’t until years later that I sought professional help and found out how common this very personal, ground-shattering experience actually was. I was diagnosed with Panic Disorder with Agoraphobia.

I. Introduction

Throughout history, anxiety and fear have been recognized as an inherent part of man’s existence. However, in antiquity, as well as late in the Middle Ages, anxiety phenomena were seldom described in a medical context, despite the fact that Hippocrates related obvious cases of phobic avoidance in a book dated around 400 BC (Hippocrates, translated in 1780). Hippocrates described the case of a man who ‘could not go near a precipice or over a bridge, or beside even the shallowest ditch; and yet he could walk in the ditch himself’. It was only in the 19th century that panic emerged as a fundamental problem, and since then, anxiety symptoms in the context of phobic avoidance have become firmly embedded in a medical context. (Den Boer, J.A., S3)

II. Defining Panic

There have been some revisions to what constitutes panic attacks and panic disorder in recent years. Panic attacks were first defined in 1980 in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, as “the sudden onset of intense apprehension, fear, or terror, often associated with impending doom”. (Barlow, David H., p. 553) This definition was revised in 1987 to include a minimum of 4 out of 13 panic symptoms. (listed below) And “sudden onset” was now defined as reaching peak intensity within 10 minutes. Also, to meet DSM-III-R criteria, one must experience a spontaneous or unexpected panic attack. With many other disorders sharing the same criteria there was a diagnostic dilemma. To further understand and diagnose these disorders, panic attack definition was revised once again in 1994 in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. This definition is now more precise and data driven the previous definitions. Many of the criteria remained the same for this new definition but emphasis was on the placement of these criteria. Criteria for panic disorder now reads “recurrent, unexpected panic attacks” and “attacks followed by a month (or more) of: persistent concern about having additional attacks, worry about the implications of the attack and its consequences, or a significant change in behavior related to the attacks.” (Barlow, David H., p553-554) Much remains unknown, including very basic questions on the relationship between panic and anxiety. Consequently, the definitions of panic attacks and panic disorder that are specified in the DSM-V should be considered a beginning rather then the final word on these issues. (Barlow, David H. p. 561)

13 Symptoms of a Panic Attack as listed in DSM-IV Criteria 1. Palpitations, pounding heart, or accelerated heart rate 2. Sweating 3. Trembling or shaking 4. Sensations of shortness of breathe or smothering 5. Feeling of choking 6. Chest pain or discomfort 7. Nausea or abdominal distress 8. Feeling dizzy, unsteady, light-headed, or faint 9. Derealization (feelings of unreality) or depersonalization (being detached from oneself) 10. Fear of losing control or going crazy 11. Fear of dying 12. Paresthesias (numbing or tingling sensations) 13. Chills or hot flashes

III. Causes of Panic in Young Adults

Throughout all of my research it is well documented that panic attacks and panic disorder make their first appearance in adolescents and young adults. A. Drug Use

As we know, young adults, especially those who are leaving home for college, are likely to experiment with drugs and alcohol. Up to 30% of patients presenting with panic disorder can cite clearly an unfavorable experience with drugs such as anesthesia, cocaine, or marijuana as the setting for their first panic. (Barlow, David H. p. 561) Drugs such as cannabis, besides being common, are associated with a variety of adverse events such as emergency room visits, physical health disorders, fatal automobile accidents, impaired educational attainment, and reduced workplace productivity. Anxiety-oriented studies have found that cannabis use can acutely precipitate heightened levels of anxiety and panic attacks among certain individuals. (Zvolensky, Michael J., p. 478) Individuals with high levels of Anxiety Sensitivity are more apt to experience symptoms. Anxiety sensitivity has been described as a fear of anxiety symptoms based on the belief that these symptoms have harmful consequences. Anxiety sensitivity are not believed to be caused

by previous panic experiences but instead it is viewed as an important psychological risk factor in the development of panic disorder. College students with levels of anxiety sensitivity have been found to report more symptoms in response to voluntary hyperventilation compared to those with a low level of anxiety sensitivity. (Cox, Brian J., p. 833) Among participants in Zvolensky’s experiment, those with a positive history of both cannabis use and panic attacks, the mean age of onset for drug use was 19 years of age and the mean age of onset of panic attacks was 19 years of age. Among those with a history of panic attacks with no cannabis use, the mean age of onset for drug use was 19 years of age and the mean age of onset of panic attacks was 27.6 years of age. Thus, panic attacks have a significantly earlier age of onset among cannabis users than among the larger population that do not use cannabis. (Zvolensky, Michael. J., p. 482) A substantial portion of individuals with co-morbid substance use and panic disorders report that their substance use disorder began before their panic disorder. In support of the notion that substance use may induce panic attacks, cocaine abusers have been found to be at an increased risk of panic disorder. (Deacon, Brett J., p. 8) B. Alcohol Use

Alcohol abuse is associated with an increased risk of panic attacks. (Zvolensky, Michael J., p. 483) Patients with panic disorder before the age of 18 have higher incidences of alcohol use. (Mildred, Barbara, p. 307) It is very common for those with panic disorder to self-medicate by using alcohol and other sedatives. The DMQ (Drinking Motives Questionnaire) consists of three five-item scales: coping motives, enhancement motives, and social motives. Coping motives refer to drinking to reduce or

avoid negative affective states such as anxiety or depression. Enhancement motives refer to drinking to increase or maintain positive affective states. Social motive refer to drinking to achieve social goals such as peer approval or feelings of affiliation. In Deacon’s examination of alcohol use and panic attacks he found that panickers and non-panickers did not significantly differ in the alcohol use composite. Panickers did not score significantly higher on the coping motives scale, all reported drinking for enhancement motives, and, particularly, social motives more than coping motives. In his evaluation he found that non-clinical panickers were more likely to use sedatives. In the table below the most notable difference between panickers and non-clinical panickers is sedative use.
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C. Stressful Life Events

Evidence of panic attacks are thought to be influenced by multiple risk factors. The reported pathogenesis of panic attacks includes gender difference, exposure to pathogenic parental rearing, personality, previous history of major depression, and recent stressful life events. Young adults are faced with a number of stressful life events. They are faced with the decisions and challenges of going to college, succeeding, determining

what they are going to do for a career, separation from their parents, moving out on their own, etc. In Watnabe’s study of prediction of first episode of panic attacks he found that three predictors (neuroticism, life time history of major depression, and recent stressful life events) had a direct effect on the risk of the first episode of panic attack. People experiencing recent stressful life events had a three time more likely chance to experience their first episode. Recent stressful life events were the strongest predictor of a first episode of panic attack. (Watanabe, Akira, p.119-126) D. Neurochemical and Neurobiological

The neurochemical and neurobiological origins of panic disorder are believed to be related to serotonin (5-hydroxytryptamine (5-HT)) function. Two opposing hypotheses have been put forth to explain panic phenomena by 5-HT-ergic dysfunction: 5-HT excess or overactivity and 5-HT deficit or underactivity. Accumulating evidence from clinical and experimental research and genetic studies points to a substantial impact of the 5-HT system on the neurobiology of panic disorder, and supports the proposed specific inhibitory influence of 5-HT on panic. (Maron, E., p. 8)

IV. Treatment

A. Antidepressants Since depression occurs as a comorbid condition in 60% of patients with panic disorder, the use of antidepressants is a logical choice. (Westenberg, H.G.M., p. S13) Antidepressant medications have been shown to reduce panic severity, eliminate attacks, and improve overall quality-of-life measures in patients with panic disorder. Two recent meta-analyses found that selective serotonin reuptake inhibitors (SSRIs) and trycyclic

antidepressants (TCAs) are equally effective in reducing panic severity and the number of attacks. The choice of antidepressant should be based on side effect profiles and patient preferences. (Ham, Peter, p. 735) B. Cognitive Behavior Therapy Cognitive Behavior Therapy (CBT) includes many techniques such as applied relaxation, exposure in vivo, exposure through imagery, panic management, breathing retraining, and cognitive restructuring. Meta-analyses support the efficiency of CBT in improving panic symptoms and overall disability. It is unclear which component of CBT is more important: cognitive therapy (e.g., identifying misinterpreted feelings, educating patients about panic attacks) or behavior therapy (e.g., breathing exercises, relaxation, exposure). (Ham, Peter, p. 736)

Benzodiazepines

Benzodiazepines are as effective as antidepressants in reducing panic symptoms and frequency of attacks, are well tolerated, and have a short onset of action. However, benzodiazepines may cause depression and are associated with adverse effects during use and after discontinuation of therapy. (Ham, Peter, p. 737) The disadvantages are dependence and withdrawal problems and are less suitable for long-term use. (Westenberg, H.G.M., p. S13)

Table from DSM-IV

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V. Conclusion

Panic symptoms are quite frequent in the community (13.1%) with a lifetime prevalence of DSM-IV panic attack at 4.3%. Women are considerably more likely to have panic disorder and have an earlier age of onset then males. (Reed, V., p. 335) In a study done by Gabriel Reed, he found that panic disorder tends to be chronic in about 66 percent of patients. Of those who remain chronic, spontaneous panic attacks disappeared

by the age of 52.6. (Reed, Gabriel, p. 2) Only 1 in 5 people experiencing panic disorder seek treatment. (Essau, Cecilia, p. 19) Occurrence of DSM-IV panic attacks are strongly related to the subsequent development of various forms of mental disorders- not only panic disorder and agoraphobia. The conditional probability of those with panic attacks to develop other forms of mental disorders are 63% for males and 40 % for females. Particularly, ‘late onset’ panic attacks (after the age of 18) are associated strongly with the development of multimorbidity of mental disorders. This suggests that panic attacks are generally highly indicative for more severe psychopathology and not only for panic disorder and agoraphobia. (Reed, V., p. 335) There are a range of pharmacological and psychological interventions that are effective in treating panic disorder. Thoughtful application of the available therapies, alone or in combination, may enable patients who have been impaired for years to regain confidence in their ability to function in society. (Westenberg, H.G.M., p. S16) In my own case, I have been on multiple forms of antidepressants and benzodiazepines for 10 years now. They honestly do work wonders and have allowed me to pursue goals, go places, and do things that I never thought I would have been able to do. I do not attend therapy, although I probably should, but since I have found the right mix of medications it is not needed at this time. The fear is always there but when those times come I am prepared to deal with them because I have the knowledge and medication to battle them.

Works Cited

Barlow, David H.; Brown, Timothy A., Definitions of Panic Attacks and Panic Disorder in the DSM-IV: Implications for Research, Journal of Abnormal Psychology, Aug94, Vol. 103, Issue 3, p. 553
Cox, Brian J.; Endler, Norman S.; Swinson, Richard P., Anxiety Sensitivity and Panic Attack Symptomatology, Behavior Research and Therapy, Sep95, Vol. 33, Issue 7, p. 833-836
Deacon, Brett J.; Valentiner, David P., Substance use and Non-Clinical Panic Attacks in a Young Adult Sample, Journal of Substance Abuse, Jan00, Vol. 11, Issue 1, p. 7-15
Den Boer, J.A., Defining Panic- A Diagnostic Dilemma, Human Psychopharmacology: Clinical & Experimental, Jun97 Supplement 1, Vol. 12, p. S3-S6
Essau, Cecilia A.; Conradt, Judith; Petermann, Franz, Frequency of Panic Attacks and Panic Disorder in Adolescents, Depression & Anxiety (1091-4269), 1999, Vol. 9 Issue 1, p. 19-26
Ham, Peter; Waters, David B.; Oliver, M. Norman, Treatment of Panic Disorder, American Family Physician, Feb05, Vol. 71, Issue 4, p. 733-739
Maron, Eduard; Shlik, Jakov, Serotonin Function in Panic Disorder: Important but Why?, Neuropsychopharmacology, Jan06, Vol. 31, Issue 1, p. 1-11
Milrod, Barbara; Busch, Frederic; Shapiro, Theodore; Leon, Andrew C.; Aronson, Andrew, A Pilot Study of Psychodynamic Psychotherapy in 18- to 21-Year-Old Patients with Panic Disorder, Adolescent Psychiatry, 2006, Vol. 29, p. 286-314
Reed, V.; Wittchen, H-u., DSM-IV Panic Attacks and Panic Disorder in a Community Sample of Adolescents and Young Adults: How Specific are Panic Attacks?, Journal of Psychiatric Research, Sep98, Vol. 32, Issue 6, p. 335-345
Rubio, Gabriel; Lopez-Ibor, Jr., Juan Jose, What Can Be Learnt from the Natural History Anxiety Disorders?, European Psychiatry, Mar07, Vol. 22, Issue 2, p. 80-86
Watanabe, Akira; Nakao, Kazuhisa; Tokuyama, Madoka; Takeda, Masatoshi, Prediction of First Episode of Panic Attacks Among White-Collar Workers, Psychiatry & Clinical Neurosciences, Apr05, Vol. 59, Issue 2, p. 119-126
Westenberg, H. G. M., Panic Disorder- a Condition for Life? Treatment Issues, Human Psychopharmacology: Clinical & Experimental, Jun97 Supplement 1, Vol. 12, p. S13-S17
Zvolensky, Michael J.; Bernstein, Amit; Sachs-Ericsson, Natalie; Schmidt, Norman B.; Buckner, Julia D.; Bonn-Miller, Marcel O., Lifetime Associations Between Cannabis, Use, Abuse, and Dependence and Panic Attacks in a Representative Sample, Journal of Psychiatric Research, Sep06, Vol. 40, Issue 6, p. 477-486