Panic and Agoraphobia

by Helen Farrell, MD

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    00:01 Now, we’re going to talk about panic, one of the very common disorders and symptoms under the anxiety class.

    00:10 Here’s a case example.

    00:12 Jennifer is a 32-year-old woman who complains of fear of going to the grocery store.

    00:18 But beyond fear, she experiences physical symptoms like shortness of breath, chest pain, numbness and tingling in her extremities, and nausea whenever she goes out shopping.

    00:30 For these reasons, she avoids going out and has completely stopped grocery shopping altogether and rather she has a food delivery service come to her apartment.

    00:41 Keep that case in mind as we talk a little bit more about panic.

    00:44 So there’s a difference between having a panic attack and a panic disorder.

    00:49 A panic attack is not actually a mental disorder.

    00:53 It’s a discrete period of heightened anxiety that affects much of the general population.

    01:01 Panic disorder, however, is characterized by the experience of panic attacks that are accompanied by a persistent fear of having additional attacks.

    01:14 So what’s the different between a panic attack and panic disorder? Well, here’s a little quiz.

    01:19 Which one is a mental disorder? Panic disorder is, not an attack.

    01:25 And which one is chronic? Exactly.

    01:28 Panic disorder, which is what makes it a disorder.

    01:32 It’s not only an acute state, but it actually lingers with associated fears of having another attack.

    01:39 So what’s the chance of developing panic disorder? As we just said, panic attack is very common.

    01:45 Almost all of us will experience panic to some degree or another throughout our lives, but only 2-5% of us will actually develop panic disorder.

    01:55 Women are going to be twice more likely to develop this than men.

    01:59 And the usual onset is by early thirties and it’s more common people who have a family history or other mental disorders in that individual.

    02:11 So what are some of the comorbidities or other mental disorders that are highly associated with panic disorder? Well, PTSD is one.

    02:20 What’s PTSD? Well, this is posttraumatic stress disorder.

    02:25 And it’s a response to a catastrophic life experience in which the patient reexperiences the trauma, commonly through a flashback, and they avoid reminders of the events and experience emotional numbing and hyperarousal.

    02:42 PTSD is very disruptive to people’s day to day lives.

    02:46 Another common mental disorder that goes along with panic disorder is this: Generalized anxiety disorder.

    02:55 This is a persistent excessive anxiety and hyperarousal about general daily events.

    03:02 It tends to last more than six months and does not generally interfere with activities of daily living.

    03:09 So how does panic disorder develop? Well, it results from a combination of underlying predispositions interacting with or triggered by some kind of stress.

    03:20 So we consider it double diaphysis model.

    03:23 There’s some kind of underlying, maybe genetic predisposition, and then there’s a life event or stress that just exacerbates the panic disorder.

    03:33 Their vulnerability factors including genetics as I just said, also childhood adversity and personality traits sometimes also make one vulnerable to a panic disorder later in life.

    03:46 So in terms of the vulnerability factors, if a first degree relative is affected, then a person is four to eight times greater at risk for having a panic disorder.

    03:59 Anxious temperaments are also vulnerable to developing panic disorder.

    04:04 And neuroticism, which is poor stress resilience to catastrophic events and also any kind of poor stress resilience when it comes to regarding bodily sensations can lead to vulnerability for panic disorder.

    04:23 A history of physical and sexual abuse also increases one's risk.

    04:28 And smoking also creates a greater likelihood of panic.

    04:33 So can asthma.

    04:35 And now, I ask, how can a neurotic personality lead to panic? Well, people with neurotic personalities tend to misinterpret things.

    04:46 So for example, they may go out for a run and experience a rapid heartbeat.

    04:51 But instead of linking that to the fact that they just exercised, this person who’s very neurotic may think, “Oh, my gosh. My heart is beating fast." And therefore they start to panic.

    05:02 Neuroticism can lead to panic, which actually can worsen and prolong the experience.

    05:07 So it’s really a vicious cycle.

    05:10 In terms of neurobiology, there are differences in the brains of those with panic disorders.

    05:17 Many intricate neural pathways involved and the various areas of the brain are affected.

    05:24 Certain receptors and neurotransmitters can also be altered.

    05:28 So when we think of neurobiology, there’s a proposed neuroanatomical model for panic disorder that focuses on specific areas within two regions of the brain.

    05:39 The amygdala and hypothalamus.

    05:42 And these tend to be sites for neural triggers to having panic attacks.

    05:48 This suggests that individuals may inherit specific areas that are hyperexcitable and yet, another theory for how a patient develops panic is that exposure to internal or external stressors leads to lighting up the excitable parts of their brain and precipitating a panic.

    06:12 The brain areas that are involved in panic include the amygdala, the prefrontal and temporal cortex, the anterior cingulate, the insula, hippocampus, and hypothalamus.

    06:26 That suggests that the human panic response is very complex.

    06:31 And it actually involves a broad set of neural networks and processes.

    06:38 Alterations in the GABA benzodiazepine receptor and serotonin receptor systems also show that panic disorder patients have increased fear generalization, meaning that even the smallest trigger can incite fear in them whereas with other people, they’re able to keep their emotions at bay.

    07:02 Spontaneous episodes of fear in people with panic disorder tend to begin abruptly, lasts for anywhere from a minute to an hour and patients with panic attacks can develop agoraphobia.

    07:15 This is an anxiety about and avoidance of situations where help or easy escape may not be quite ready.

    07:24 And people will often fear having embarrassing symptoms when they’re out in a public place when they’re agoraphobic.

    07:32 Panic and spontaneous episodes of fear also are often accompanied by somatic features, things like faster breathing, rapid heartbeat, sweating, sometimes are associated with agoraphobia, which is where the patient won’t leave the house for months or even days on end, they avoid social contact in situations where they perceive that they’re going to be caused to be in a fearful situation.

    08:07 So let’s go back to this woman, Jennifer.

    08:09 So we know that she’s quite fearful of the marketplace and grocery shopping.

    08:13 She’s pretty much starting to seclude herself at home and so I asked does Jennifer have agoraphobia? Well, yes. She does.

    08:23 She’s fearful of going out in public because she fears having another panic attack in a very public space that she may not be able to get out of very readily.

    About the Lecture

    The lecture Panic and Agoraphobia by Helen Farrell, MD is from the course Anxiety and Stress-Related Disorders. It contains the following chapters:

    • Panic
    • How Does Panic Disorder Develop?
    • Vulnerability Factors
    • Neurobiology

    Included Quiz Questions

    1. It is a mental disorder.
    2. Its presents as sudden onset of shortness of breath, chest pain, numbness and tingling in the extremities along with nausea.
    3. It affects much of the general population.
    4. It is a discrete period of heightened anxiety.
    5. It is an acute episode of fear.
    1. Generalized anxiety disorder
    2. Major depression
    3. Schizoaffective disorder
    4. Bipolar disorder
    5. Bulimia Nervosa
    1. A response to a catastrophic life event where the patient re-experiences the trauma.
    2. Alternating episodes of panic and anger as a response to major trauma.
    3. Persistent, excessive anxiety and hyperarousal about daily general events.
    4. Experience of panic attacks accompanied by a persistent fear of having additional attacks.
    5. A brief episode of depressed mood associated with suicidal intentions.
    1. Alcoholism
    2. Asthma
    3. Sexual abuse
    4. Neuroticism
    5. First-degree relative affected by the disorder
    1. GABA-benzodiazepine receptors and serotonin receptor systems
    2. Dopamine receptors and NMDA receptors
    3. NE receptors and dopamine receptors
    4. Glutamate receptors and NE receptors
    5. NMDA receptors and glutamate receptors
    1. Fear of public or crowded places
    2. Fear of enclosed spaces
    3. Fear of heights
    4. Fear of fire
    5. Fear of blood or injury

    Author of lecture Panic and Agoraphobia

     Helen Farrell, MD

    Helen Farrell, MD

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