Panic Disorder Causes, Symptoms, Treatment, Ayurveda Concept

By Dr Raghuram Y.S. MD (Ay) & Dr Manasa, B.A.M.S
Panic is a type of severe fear. They come in the form of attacks. Panic attacks can be defined as – ‘an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes’ (DSM-5)

In short, panic attacks are when you feel suddenly occurring overwhelming terror which comes with no obvious cause. Physical symptoms like racing heart, breathing difficulties and sweating occur.

Panic attacks can be frightening. When they occur, the patient feels as if losing control over self and situations, experiences a heart attack or near-death experience. They can occur at any time. Panic attacks can occur when you are at a mall, driving a car, when you are in a meeting or when you are sound asleep. The panic attacks may occur occasionally or even frequently.
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Panic Attack and Common fear

The panic attacks cause ‘sudden and brief spells of fear along with strong physical reactions’. Peculiarly they occur in response to situations which are ordinary and non-threatening in nature. These situations do not cause fear in other people in the way they do in these people. During the attack the person will sweat a lot and will find it difficult to breathe and also will sense that his or her heart is racing beyond control. There is a feel of experiencing a ‘heart attack’. When the person worries beyond limit about having yet another panic attack or when he changes his behaviors to avoid having a panic attack, there are more chances that he develops panic disorder.

Incidence of Panic Attacks – About 11% of Americans approximately experience a panic attack every year. Approximately 2-3 % of them go on to develop panic disorder.
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Who is prone to get panic attacks?

Anyone can experience panic attacks. These attacks first occur typically during teenage or during early adult years. People of all ages can have panic attacks including children. Women suffer from panic disorder twice in comparison to men.

Many people experience panic attack at least once or twice in their lives. A study tells that 2-4% people have a panic disorder (2019). In some people the problem may disappear when the stressful situation ends.

Panic disorder – Some people who suffer from panic attacks fear so much about their attacks that they develop panic disorder. It is a type of anxiety disorder. It is defined by ‘at least 1 month of persistent fear about panic attacks (or their effects) reoccurring’. In short, panic disorder occurs when you experience ‘recurring, unexpected and sudden panic attacks’.

Symptoms of panic disorder often start to appear in between 20-24 years of age. If you have 4 or more panic attacks you might have a panic disorder. You may also have panic disorder if you live in fear of having yet another panic attack after having experienced one attack.

The symptoms of panic disorder can be frightening and overwhelming. They can be managed and improved with prompt and comprehensive treatment. The patient needs to know that he needs to seek help for getting treated. If he doesn’t ask for help the condition may get worse. When treated in the right time the symptoms of panic disorder will get reduced and would improve the quality of life of the patient.

Panic disorders are also associated with significant events of life and life changes. Major life transitions like going to a college, getting married; having a first child etc might create stress and lead to development of panic disorder.
Read – Help Your Children Deal With Their Feelings

Causes

The exact causes for panic attacks or panic disorder are not known. Your brain has a major role in determining how you would be able to perceive and handle fear and anxiety. You might be at increased risk of developing panic attacks if you have

a.  Genetics – Family history of panic disorders or anxiety disorders (some researchers have established genetic link of panic disorder, while other studies weren’t successful in doing so)

b.   Major stress – If you have anxiety disorders, depression or other mental illnesses

c.   Habits – If you are victim of substance abuse including alcoholism and drug addiction

d.   Temperament – If you have a temperament that is more sensitive to stress or if you are prone to negative emotions

e.  Brain – certain changes in the way the parts of your brain function might cause panic attacks

Though the panic attacks come suddenly and without warning at beginning they later occur being triggered by certain situations.
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Symptoms

Panic attacks occur suddenly, without warning. Once the panic attack starts there is no way to stop it. Immediately after the attack starts the symptoms of panic attack usually peak within 10 minutes. An attack typically lasts for about 5-20 minutes. The symptoms can continue to be for an hour or so in extreme cases. For everyone the symptoms, duration, intensity and experience vary. The symptoms usually disappear after a few minutes. You may experience fatigue and wear out once the panic attack subsides.

Below mentioned are the signs of panic attack

Racing heart / palpitations and pain or tightness in the chest
Difficulty in breathing
Choking / smothering sensation / Tightness in your throat
Intense feel of terror and fear
Sense of impending doom / danger
Trembling
Fear of losing control over everything and situations getting out of control
Severe sweating
Tingling / numbness in fingers / toes
Dizziness / fainting
Feeling of detachment
Derealization (feeling of unreality)
Depersonalization (being detached from oneself)
Feeling of death approaching
Chills
Nausea
Hot flashes
Abdominal cramping
Headache

The worst part of panic attacks is the intense fear that you might have yet another attack. The fear is so intense that you will avoid certain situations where panic attacks might occur. Typically the symptoms are disproportionate to the level of danger, fear or threat that prevails in your environment. They cannot be predicted and hence can significantly meddle with your everyday life.
Read – Ways To Handle Anxiety Depression Symptoms With Ease

Diagnosis

Panic attacks are diagnosed after thorough examination and also a series of tests if needed. Diseases like heart disease, respiratory problems and thyroid disease can cause symptoms similar to those of panic attacks. The tests and exams are done to rule out physical problems.

Apart from thorough physical examination you may need to undergo the below mentioned exams to get diagnosed as suffering from panic attacks / panic disorder –

Blood tests to check for thyroid values and other possible conditions
Tests to check heart condition (ECG, EKG)
Psychological evaluation – wherein you can freely talk about your fears, concerns, stressful situations, problems related to relationship, situations you would avoid, family history of mental disorders / panic attacks

You may be asked to fill in a self-assessment psychological questionnaire and you might also have to give an account of your substance abuse or addictions if any.

Panic disorder is diagnosed when you have repeated panic attacks. Everyone who has panic attacks need not have panic disorder. The diagnosis is made on the below mentioned points –

1. Should have frequent and unexpected panic attacks
2. Should experience the below mentioned –
– at least one of your panic attacks should have been followed by 1 month or more of ongoing worry about having another similar attack,
– continued fear of the consequences of panic attack (like losing control, having heart attack, going crazy etc),
–  significant changes in behavior like avoiding situations that you may feel might trigger your panic attack or bring about the symptoms
3. Panic attacks should not have been caused by
Drugs or substance abuse
A medical condition
Another mental health condition such as OCD, social phobia etc

You may have panic attacks but still not be diagnosed with panic disorder. If panic attacks are not promptly treated they will get worse with time and develop into panic disorders or phobias.
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What is the right time to see the doctor?

Many times symptoms of panic disorder / attacks will resemble a heart attack. Call for immediate medical help if you experience chest pain, difficulty in breathing or loss of consciousness.

If you have the panic attacks and experience the below mentioned conditions you need to call your doctor immediately –

Symptoms of panic attack that last longer than 15 minutes
Chronic anxiety which interferes daily life activities
Difficulty in concentrating
Extreme irritability
Agoraphobia (fear of leaving home alone)
Sleep problems
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Risk Factors

Family history (of panic attacks / disorder)
Major stress (death or serious illness of loved ones)
Traumatic event (sexual assault, serious accident etc)
Major changes in life (divorce, addition of another baby to the family)
Habits – smoking, excessive caffeine
History of physical or sexual abuse in childhood

Women are more likely to develop this disorder (National Institute of Mental Health). According to research works anxiety disorders such as panic disorder are more common in women than in men. Panic disorder is also common in teens and young adults in comparison to people of other age groups.
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Complications

If not treated at proper time and interventions panic attack or disorder can affect every aspect of life. The fear of getting repeated panic attacks is so severe that you would live in a constant state of fear. This will eventually ruin the quality of your life.

Below mentioned are the complications caused by panic attacks
Specific phobias – like fear of leaving home, fear of driving, fear of heights etc
Frequent medical care for health issues, concerns or other medical conditions
Problems at work and school
Avoidance of social situations
Depression
Anxiety disorders and other psychiatric disorders
Agoraphobia
Increased risk of suicide
Increased thoughts of suicide
Financial problems
Alcohol misuse
Substance abuse

Anticipatory anxiety – Extreme anxiety may be triggered by the feeling of possibility of having a panic attack once again. This is also a complication of panic attacks / disorders.

Prevention

Panic disorder is a long-term condition. It is often very difficult to treat it. May don’t respond well to treatment. Many people may have the disease with severe symptoms at times and almost no symptoms at other times. Most people may find relief of symptoms through properly implemented treatment.

There is no definitive way to prevent panic disorders or panic disorders.

Your doctor / healthcare provider is the best person who may help you to identify the triggers of your panic attacks. You would learn strategies to manage triggers and also prevent impending attacks while you undergo psychotherapy. Below mentioned are useful methods to lower the chances of getting panic attacks –

Eat healthy diet
Manage your stress by using best methods which help you
Regularly exercise
Cut back on caffeine
Avoid alcohol and stimulants
Ger treatment for panic attacks as soon as possible
Stick to the treatment plan to prevent relapses or worsening of symptoms
Speak about your problems openly with your mental health professional / healthcare provider
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Lifestyle and home remedies

The lifestyle and home remedies will form an important aspect of self-care strategy. They may help in managing the symptoms but are not a cure for the disorder.

Take a regular plan and stick to your treatment plan – will help in keeping your symptoms under control and give you relief from your condition.

Join a support group – This will help you to connect with many other people who have similar problems and gain courage. It will assure you that you are not the only person suffering from this problem and hope that you can beat your symptoms with proper approach.

Avoid – caffeine, alcohol, smoking, recreational drugs and other substance abuse.

Regularly practice stress management and relaxation techniques – Regular practice of Yoga, deep breathing and progressive muscle relaxation will help.

Physical activity – You should get regular physical activity. Exercise to your capacity and regularly practice it. Aerobic activity will have a soothing effect on your mood.

Sleep – Get enough sleep during the night. This will prevent you from getting drowsy during the day time. This will also help in relieving your symptoms of panic attack to an extent.
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Treatment

Prompt and comprehensive treatment is needed to have the symptoms of panic disorder under control. It will help to reduce the intensity and frequency of your panic attacks. It will also help you to indulge in your life activities and also improve your functions in daily life.

Psychotherapy, medications or a combination of both would effectively help in stopping panic attacks. The severity of your symptoms and problem will determine the duration of your treatment and the response to it.

Psychotherapy – CBT (Cognitive Behavioral Therapy) is a type of psychotherapy or talk therapy. It is a useful strategy in dealing with panic symptoms / panic disorder. It is in fact the first choice treatment for this disorder. You may discuss in detail about your emotions and thoughts with a mental health professional, counselor or psychologist. They will help you in identifying the triggers of your panic attack. You can use this help to change your thinking, behaviors and reactions. Psychotherapy will help you to understand the nature of the disease, its symptoms and ways of coping with them. CBT will help you learn through your experience that panic symptoms are not as dangerous as you think they are. In this therapy your therapist / physician will help in re-creating the symptoms of panic attack in a safe and repetitive manner. The attacks start deteriorating once the physical sensations no longer feel threatening to you and as you grow confident of handling them on your own. Treatment will also help you to get on top of your fears of situations that you have and are avoiding because of panic attacks. It may take time to respond. Symptoms may reduce in several weeks. Many times the symptoms decrease significantly and go away within several months. You need to schedule regular meetings and sessions with your doctor to keep a track on the relief of your symptoms and also treat or avoid recurrences.

Medications – They can help in reducing symptoms associated with panic attacks. They may also relieve depression and anxiety associated with panic disorder. Many medications are shown to be effective in managing symptoms of panic attacks. They are –

Antidepressants – Some medicines of this category will make panic attacks less frequent or less severe. The below mentioned medicines may be prescribed –
SSRI – Serotonin Selective Reuptake Inhibitors
SNRI – Serotonin Norepinephrine Reuptake Inhibitors
TCA – Tricyclic Antidepressants
MAOIs – Monoamine Oxidase Inhibitors
Anti-seizure drugs

Anti-anxiety Medications – Benzodiazepines are most commonly prescribed to treat and prevent panic attacks.
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Prognosis

Most people with panic attacks get better with prompt treatment. One should not hesitate from asking for medical help once the signs of panic attack are noticed. If neglected and not treated at proper time ongoing panic attacks might shape up into panic disorder. So earlier the treatment is given better and earlier the results would be.

Research

Study of Psychotherapy for panic disorder – Psychotherapy gives good results for panic disorder. Effects of the therapy are long standing. It was found that even after 2 years of treatment 70 % patients clearly improved and 45% were remitted.

Family study of Panic Disorder – The study concluded that ‘this disorder is familial’ and it affects women twice as frequently as men and is not associated with an increased familial risk of other psychiatric conditions. Method of transmission of this disorder remains uncertain.

A study – The relationship between Panic disorder and Major Depression – It was concluded that panic disorder and Major Depressive Disorder are separate disorders with substantial co-occurrence in individuals and panic comorbid with MDD is not a single distinct disorder.

Panic Disorder and Major Depression – Major depression with panic disorder in probands was associated with a marked increase in risk in relatives of a number of psychiatric disorders relatives were more than twice as likely to have major depression, phobia, panic disorder or alcoholism than the relatives of probands with major depression without any anxiety disorder.
Click to Consult Dr Raghuram Y.S. MD (Ayu)

Ayurveda Concept of Panic Disorder

Charaka Samhita Sutrasthana 7th chapter –

A wise person should suppress bhaya – fear. Here, fear is explained as a mental quality that should be suppressed, along with greed, grief, anger, shamelessness, jealousy, etc. It indicates that we should fight against fear all the time.

Acharya Charaka explains constant fear as an exogenous disorder. The disease affecting a person due to external causes. These are called Agantuja roga. Acharya Charaka explains,

Bad emotions such as
Irshya – malice, jealous
Shoka – despair, grief
Bhaya – fear
Krodha – anger
Mana – vanity and
Dvesha – hatred, etc mental disorders are due to Prajnaparadha – knowingly doing wrong things.

These two references hint that, we should suppress the fear or phobia, first time when it appears in the mind. If we neglect it, it gets auto-nurtured and it grows big.
All efforts should be made all the time to keep the mind fear-free.

In the very next paragraph, Charaka writes,

Prevention of exogenous diseases- Agantuja Roga:

These Agantu rogas can be prevented by
Avoiding Prajnaparadha – acting as per one’s right conscience,
Indriyopashama – control over sense organs,
Smruti – Keeping God in memory,
Desha, Kala Atma Vijnana – knowledge of the place, time and one’s own soul and
Sadvrutta – good conduct

Aptopadesha (Knowledge about the prescription and advice of ancient authority sages),
One desirous of his own well-being should follow this, in advance. [53-54]

This indicates that following healthy code of conduct, following rule of the land, living as per the law, respecting elders, King etc., reading books written by wise people, being knowledgeable, being devotional, spiritual and having a good control over sense organs are means to inculcate fearless mindset.

Charaka Samhita, Vimanasthana 2/9

When the mind is afflicted with fear, anxiety, anger, delusion, jealousy, if the person sleeps for long hours or sleeps for less hours etc., the food, though taken in normal quantity, will not undergo proper digestion.

This shows that fear and anxiety can decrease once digestion strength.

Charaka Samhita Chikitsa Sthana 1.2-2
Bad habits that cause illness : daily indulgence in day-sleep, sex, alcohol
irregular, excessive exercise, excessive fear, anger, grief, greed, infatuation and over-work – these cause increase of Dosha and various disorders.

Charaka Samhita, Chikitsa Sthana 3/114 -115
Excess desires, fear, phobia and depression cause increase of Vata Dosha, that leads to fever.

In the first stage of Jwara, Langhana or fasting is prescribed. It is however, not indicated in the fevers caused by severe tissue depletion, aggravation of Vata due to fear, anger and depression. [139–140]

This indicates that nourishing, Vata balancing diet and oil and ghee-based medicines that calm mind and balance Vata Dosha, such as Brahmi ghrita, Kalyanaka ghrita, ksheerabala 101 oil etc. are prescribed to overcome fear, phobia and its effects on mind. 

Charaka Samhita, Chikitsa Sthana 9th chapter

Fear, greed, depression etc., on a long term can cause psychiatric disorders. The way to treat them is, by imbibing opposing qualities.
The fear is treated by increasing the courage in the patient.

Fear is explained as a causative factor for anemia and malnourishment.

References from Ashtanga Hrudayam of Acharya Vagbhata:
Ashtanga Hrudaya Sutrasthana 1st chapter:
Fear causes delaying in wound healing.
Uttarasthana 39th chapter – There is a type of antiaging treatment where the person resides in a hit for many weeks. While entering the hut, patient should have undergone Panchakarma and patient should be fearless. If he is phobic, the antiaging treatment might not yield desired results.

Since Panic disorder is an anxiety disorder it needs to be treated on the lines of ‘Chittodvega Chikitsa’. The other treatment principles would be –
Treatment on the lines of treating ‘vitiation and contamination of mind carrying channels’
Treatment on the lines of Unmada
Treatment on the lines of Apasmara
Treatment on the lines of Vata Vyadhi treatment

Regular practice of Yoga and Meditation will help to a greater extent.

Ayurvedic Medicines

Because panic disorder is largely due to Vata aggravation,
herbal oils and ghees are administered orally.
Herbal ghees such as Mahakalyanaka ghrita, Brahmi Ghrita, Kalyanaka Ghrita
Herbal oils for oral intake –
Ksheerabala taila 101 capsule,
Dhanwantaram oil,
Mahanarayana oil

Herbs such as Jatamansi, Shankhapushi, Gotu Kola etc. with ghee or honey as co-drink.

Ayurvedic Therapies

Shirodhara
Shiro-Abhyanga – head massage with Ksheerabala taila, Chandanadi taila, Bramhi thailam
Nasya – Nasal drops with
Brahmi thailam (If Vata Dosha, excess thinking is involved)
Brahmi ghritham with excess sweating, burning sensation and headache is involved.

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