Psychological Causal Factors of Panic Disorder

Panic disorder is characterized by the “out of the blue” panic attacks, which are recurrent, unexpected attacks and the person must be persistently concerned or worried about having another attack for at least a month. For an attack to meet the criteria of a full-blown episode, the person must have an abrupt onset of at least 4 of 13 symptoms given in DSM-V criteria. The panic episode peaks at 10 minutes, lasts for about 20 to 30 minutes maximum but not later than an hour. Panic attacks are often “unexpected “or “uncued”, in a way that they don’t seem to have an identifiable provocation of the immediate situation. 

There are 10 physical symptoms and 3 cognitive symptoms which totals to 13 symptoms, a person must have at least 4 of them to meet the DSM criteria for panic attack. Following are the symptoms:

  1. Palpitations, pounding heart or high heart rate.
  2. Sweating 
  3. Trembling or shaking
  4. Sensations of shortness of breath
  5. Feeling of choking
  6. Nausea
  7. Chest pain
  8. Feeling dizzy or light-hearted
  9. Chills or heat sensations
  10. Parenthesias (numbness or tingling )
  11. Derealization or depersonalization 
  12. Loss of control over oneself
  13. Fear of dying

Panic disorder has many causal factors but the most important ones are psychological, which are explained below:

  • Cognitive Theory of Panic: The cognitive theory regarding panic was given by Beck and adapted by D.M. Clark, with the hypothesis that the people who suffer from panic attacks have a higher sensitivity to their bodily sensations. As it is a sign of their panic attack, they assign a worry to that bodily sensation along with the perceived threat of having another panic attack. This leads to more bodily sensations which are then interpreted as catastrophic threats, resulting into a vicious circle of having a panic attack. The model proposes that these catastrophic thoughts become automatic soon after first or second panic attack and escalate the condition. (Pilecki, 2011)

 

  • Comprehensive learning theory of panic: Learning theory argues that the person goes through two types of conditioning – interoceptive and exteroceptive. The initial attacks become related to the internal and external cues which actually condition them to anxiety. The more intense the anxiety, more robust the conditioning will occur. The exteroceptive and interoceptive conditioning can range from heart palpitations, dizziness to social places like shopping malls. Most of the time a panic attack is “out of the blue” but it is the internal cues that the person was unconsciously conditioned to generate anxiety. (Acheson, 2012)

 

  • Anxiety sensitivity and perceived control: Anxiety sensitivity means that some people have a tendency to notice certain bodily sensations with harmful consequences. These people are more prone to develop panic disorder. They say statements like “When I feel dizzy, I worry that I might faint”. In addition to this sensitivity, there is a term called perceived control which means that if there is an element of safety around a person who is suffering from panic disorder, the susceptibility of a panic attack becomes low. (Dixon, 2013) (Carleton, 2014)

 

  • Safety behaviors and persistence of panic: Some people may have a panic attack four or five times a week for 20 years, each time thinking that they might have a heart attack and yet they never do. They have these “safety behaviors” in response to their perceived threat of having a heart attack or going crazy. But when the threat does not become a harmful consequence, they don’t have the ideal realization and persistently worry about having a panic attack. (van Uijen, 2017)

 

  • Cognitive biases and maintenance of panic: People with panic disorder have cognitive biases towards threatening circumstances or information. They process that threatening information a lot easily and quickly than the other types of information. They have a tendency to selectively attend to these threatening circumstances and retrieve such information from long term memory. This leads to an unconscious cue that automatically provoke the person to have another attack. 

These psychological factors have been proven to be major causes for prevalence of panic attacks in people suffering with a panic disorder. They are cognitive schemas or a mental framework that is designed for such threats and the concept of having a panic attack, which makes the attacks come “out of the blue”. 

References:

  1. Dixon, L. J., Sy, J. T., Kemp, J. J., & Deacon, B. J. (2013). Does anxiety sensitivity cause panic symptoms? An experimental investigation. Journal of Experimental Psychopathology4(2), 208-223. https://doi.org/10.5127%2Fjep.027512 
  2. Pilecki, B., Arentoft, A., & McKay, D. (2011). An evidence-based causal model of panic disorder. Journal of Anxiety Disorders25(3), 381-388. https://doi.org/10.1016/j.janxdis.2010.10.013 
  3. Carleton, R. N., Duranceau, S., Freeston, M. H., Boelen, P. A., McCabe, R. E., & Antony, M. M. (2014). “But it might be a heart attack”: intolerance of uncertainty and panic disorder symptoms. Journal of anxiety disorders28(5), 463-470. https://doi.org/10.1016/j.janxdis.2014.04.006 
  4. Acheson, D. T., Forsyth, J. P., & Moses, E. (2012). Interoceptive fear conditioning and panic disorder: the role of conditioned stimulus–unconditioned stimulus predictability. Behavior therapy43(1), 174-189. https://doi.org/10.1016/j.beth.2011.06.001 
  5. van Uijen, S., Dalmaijer, E., van den Hout, M., & Engelhard, I. (2017). DO SAFETY BEHAVIORS PRESERVE THREAT BELIEFS?. Safety behaviors and the persistence of irrational fears, 31. https://dspace.library.uu.nl/bitstream/handle/1874/359550/vUijen.pdf?sequence=1#page=31 
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