Contd. from

Causes of Panic Disorder

The National Institute of Mental Health supports a sizable and multifaceted research program on panic disorder – its causes, diagnosis, treatment, and prevention. This research involves studies of panic disorder in human subjects and investigations of the biological basis for anxiety and related phenomena in animals. It is part of a massive effort to overcome the major mental disorders, an effort that started during the 1990s – the Decade of the Brain. Here is a description of some of the most important new research on panic disorder and its causes.

Genetics. Panic disorder runs in families. One study has shown that if one twin in a genetically identical pair has panic disorder, it is likely that the other twin will also. Fraternal, or non-identical twin pairs do not show this high degree of "concordance" with respect to panic disorder. Thus, it appears that some genetic factor, in combination with environment, may be responsible for vulnerability to this condition.

NIMH-supported scientists are studying families in which several individuals have panic disorder. The aim of these studies is to identify the specific gene or genes involved in the condition. Identification of these genes may lead to new approaches for diagnosing and treating panic disorder.

Brain and Biochemical Abnormalities. One line of evidence suggests that panic disorder may be associated with increased activity in the hippocampus and locus coeruleus, portions of the brain that monitor external and internal stimuli and control the brain's responses to them. Also, it has been shown that panic disorder patients have increased activity in a portion of the nervous system called the adrenergic system, which regulates such physiological functions as heart rate and body temperature. However, it is not clear whether these increases reflect the anxiety symptoms or whether they cause them.

Another group of studies suggests that people with panic disorder may have abnormalities in their benzodiazepine receptors, brain components that react with anxiety-reducing substances within the brain.

In conducting their research, scientists can use several different techniques to provoke panic attacks in people who have panic disorder. The best known method is intravenous administration of sodium lactate, the same chemical that normally builds up in the muscles during heavy exercise. Other substances that can trigger panic attacks in susceptible people include caffeine (generally 5 or more cups of coffee are required). Hyperventilation and breathing air with a higher-than-usual level of carbon dioxide can also trigger panic attacks in people with panic disorder.

Because these provocations generally do not trigger panic attacks in people who do not have panic disorder, scientists have inferred that individuals who have panic disorder are biologically different in some way from people who do not. However, it is also true that when the people prone to panic attacks are told in advance about the sensations these provocations will cause, they are much less likely to panic. This suggests that there is a strong psychological component, as well as a biological one, to panic disorder.

NIMH-supported investigators are examining specific parts of the brain and central nervous system to learn which ones play a role in panic disorder, and how they may interact to give rise to this condition. Other studies funded by the Institute are under way to determine what happens during "provoked" panic attacks, and to investigate the role of breathing irregularities in anxiety and panic attacks.

Animal Studies. Studies of anxiety in animals are providing NIMH-sponsored researchers with clues to the underlying causes of this phenomenon. One series of studies involves an inbred line of pointer dogs that exhibit extreme, abnormal fearfulness when approached by humans or startled by loud noises. In contrast with normal pointers, these nervous dogs have been found to react more strongly to caffeine and to have brain tissue that is richer in receptors for adenosine, a naturally occurring sedative that normally exerts a calming effect within the brain. Further study of these animals is expected to reveal how a genetic predisposition toward anxiety is expressed in the brain.

Other animal studies involve macaque monkeys. Some of these animals exhibit anxiety when challenged with an infusion of lactate, much like people with panic disorder. Other macaques do not exhibit this response. NIMH-supported scientists are attempting to determine how the brains of the responsive and non-responsive monkeys differ. This research should provide additional information on the causes of panic disorder.

In addition, research with rats is exploring the effect of various medications on the parts of the brain involved in anxiety. The aim is to develop a clearer picture of which components of the brain are responsible for anxiety, and to learn how their actions can be brought under better control.

Cognitive Factors. Scientists funded by NIMH are investigating the basic thought processes and emotions that come into play during a panic attack and those that contribute to the development and persistence of agoraphobia. The Institute also supports research evaluating the impact of various versions of cognitive-behavioral therapy to determine which variants of the procedure are effective for which people. The NIMH panic disorder research program will also explore the effects of interpersonal stress such as marital conflict on panic disorder with agoraphobia and determine if including spouses in the cognitive-behavioral treatment of the condition improves outcome.

Finding Help for Panic Disorders

Self-help and support groups are the least expensive approach to managing panic disorder, and are helpful for some people. A group of about 5 to 10 people meet weekly and share their experiences, encouraging each other to venture into feared situations and cope effectively with panic attacks. Group members are in charge of the sessions. Often family members are invited to attend these groups, and at times a therapist or other panic disorder expert may be brought in to share insights with group members. Information on self-help groups in specific areas of the country can be obtained from the Anxiety Disorders Association of America.

Sources of Referral to Professional Help for Panic Disorder.

Here are the types of people and places that will make a referral to, or provide, diagnostic and treatment services for a person with symptoms resembling those described in this brochure. Also check the Yellow Pages under "mental health," "health," "anxiety," "suicide prevention," "hospitals," "physicians," "psychiatrists," "psychologists," or "social workers" for phone numbers and addresses.

• Family doctors
• Clergy
• Mental health specialists, such as psychiatrists, psychologists, social workers, or mental health counselors
• Health maintenance organizations
• Community mental health centers
• Hospital psychiatry departments and outpatient clinics
• University- or medical school-affiliated treatment or research programs
• State hospital outpatient clinics
• Family service/social agencies
• Private clinics and facilities
• Employee assistance programs
• Local medical, psychiatric, or psychological societies

There is a detailed list of organizations and contact information below.

Help for the Family

When one member of a family has panic disorder, the entire family is affected by the condition. Family members may be frustrated in their attempts to help the affected member cope with the disorder, overburdened by taking on additional responsibilities, and socially isolated. Family members must encourage the person with panic disorder to seek the help of a qualified mental health professional. Also, it is often helpful for family members to attend an occasional treatment or self-help session or seek the guidance of the therapist in dealing with their feelings about the disorder.

Certain strategies, such as encouraging the person with panic disorder to go at least partway toward a place or situation that is feared, can be helpful. The director of one anxiety disorder clinic has developed a list of suggestions for family members who want to help loved ones cope with an anxiety disorder. By their skilled and caring efforts to help, family members can aid the person with panic disorder in making a recovery.

Also, it may be valuable for family members to join or form a support group to share information and offer mutual encouragement.

What to Do if a Family Member Has an Anxiety Disorder

1. Don't make assumptions about what the affected person needs; ask them.
2. Be predictable; don't surprise them.
3. Let the person with the disorder set the pace for recovery.
4. Find something positive in every experience. If the affected person is only able to go partway to a particular goal, such as a movie theater or party, consider that an achievement rather than a failure.
5. Don't enable avoidance: negotiate with the person with panic disorder to take one step forward when he or she wants to avoid something.
6. Don't sacrifice your own life and build resentments.
7. Don't panic when the person with the disorder panics.
8. Remember that it's alright to be anxious yourself; it's natural for you to be concerned and even worried about the person with panic disorder.
9. Be patient and accepting, but don't settle for the affected person being permanently disabled.
10. Say: "You can do it no matter how you feel. I am proud of you. Tell me what you need now. Breathe slow and low. Stay in the present. It's not the place that's bothering you, it's the thought. I know that what you are feeling is painful, but it's not dangerous. You are courageous."

Don't say: "Relax. Calm down. Don't be anxious. Let's see if you can do this (i.e., setting up a test for the affected person). You can fight this. What should we do next? Don't be ridiculous. You have to stay. Don't be a coward."

(Adapted from Sally Winston, Psy.D., The Anxiety and Stress Disorders Institute of Maryland, Towson, MD, 1992.)

For More Information on Panic Disorder and Related Conditions

American Psychiatric Association
1400 K Street, N.W.
Washington, DC 20005
http://www.psych.org 

American Psychological Association
750 First Street, N.E.
Washington, DC 20002
http://www.apa.org 

Anxiety Disorders Association of America
11900 Parklawn Drive, Suite 100
Rockville, MD 20852
(Include $3 for postage and handling.)
http://www.adaa.org

Association for the Advancement of Behavior Therapy
305 Seventh Avenue
New York, NY 10001
http://www.aabt.org 

National Alliance for the Mentally Ill
200 North Glebe Road, Suite 1015
Arlington, VA 22203-3754
http://www.nami.org 

National Anxiety Foundation
3135 Custer Drive
Lexington, KY 40517-4001

National Depressive and Manic Depressive Association
740 North Franklin Street, Suite 301
Chicago, IL 60601
http://www.ndmda.org 

National Institute of Mental Health
6001 Executive Boulevard, Rm. 8184, MSC 9663
Bethesda, MD 20892-9663 http://www.nimh.nih.gov 

National Mental Health Association
1201 Prince Street
Alexandria, VA 22314-2971
http://www.nmha.org 

References

Barlow, D.H., and Craske, M.G. Mastery of Your Anxiety and Panic. Albany, NY: Graywind Publications, 1988.

Beck, A.T., and Emery, G., with Greenberg, R. Anxiety Disorders and Phobias: A Cognitive Perspective. New York: Basic Books, 1985.

Gold, M.S. The Good News About Panic, Anxiety, and Phobias. New York: Bantam, 1989.

Greist, J.H., and Jefferson, J.W. Panic Disorder and Agoraphobia: A Guide. Madison, WI: Anxiety Disorders Center and Information Centers, University of Wisconsin, 1992.

Hecker, J.E., and Thorpe, G.L. Agoraphobia and Panic: A Guide to Psychological Treatment. Needham Heights, MA: Allyn and Bacon, 1992.

Katon, W. Panic Disorder in the Medical Setting. NIH Pub. No. 93-3482. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1993.

Kernodle, W.D. Panic Disorder. Richmond, VA: William Byrd Press, 1991.

Klerman, G.L., et al., eds. Panic Anxiety and Its Treatments. Washington, DC: American Psychiatric Press, 1993.

Mathews, A.M.; Gelder, M.G.; and Johnston, D.W. Agoraphobia: Nature and Treatment. New York and London: Guilford Press, 1981.

National Institutes of Health. NIH Consensus Development Conference Statement, Vol. 9, No. 2. Treatment of Panic Disorder. Bethesda, MD: NIH, September 1991.

Rachman, S., and Maser, J.D. Panic: Psychological Perspectives. Hillsdale, NJ: Erlbaum Associates, 1988.

Sheehan, D.V. The Anxiety Disease. New York: Bantam, 1986.

Wilson, R.R. Don't Panic: Taking Control of Anxiety Attacks. New York: Harper and Row, 1986.

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Reviewed: 01/2006