Anxiety vs. panic attacks and panic disorders: Occasional feelings of anxiety are a normal part of life, but panic attacks and panic disorders are not. Anxiety is helpful because it makes us pay attention and prepare for potential risks in new situations. Some people are always on high alert, even when there is no danger. This can lead to anxiety disorders.
According to the American Psychiatric Association, anxiety disorders are the most diagnosed of all mental health disorders, affecting nearly 30% of adults at some point in their lives. There are several types of anxiety disorders listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) including generalized anxiety disorder (GAD), panic disorder, social anxiety disorder, separation anxiety, agoraphobia, and various phobia-related conditions. Most of us experience bouts of worry and anxiety as we go about our lives, but for those with an anxiety disorder the anxiety rarely goes away and can worsen over time, interfering with job performance, schoolwork, relationships, and overall quality of life.
Panic Attacks and Panic Disorders
A panic attack is a short episode of intense anxiety, lasting about 10 to 20 minutes. It causes physical and mental symptoms that can be overwhelming. Panic attacks usually happen without a specific cause and can feel like they come out of nowhere. During an attack, several physiological symptoms can occur in combination, including:
- Heart palpitations, or a pounding, rapid heart rate
- Sweating
- Trembling or shaking
- Shortness of breath, the inability to catch one’s breath, hyperventilation, or feelings of being smothered or choked
- Chest pain
- Feelings of dizziness or light-headedness
- Numbness or tingling
- Chills or hot flashes
- Nausea or abdominal pains
The physical symptoms mentioned can be very severe and unexplained, leading to psychological symptoms like anxiety or depression:
- Feelings of detachment or unreality
- The fear of losing control
- The fear that one is having a heart attack or is dying
- The fear that one is going crazy
- Feelings of impending doom
Some panic attacks do have discernable causes (e.g., experiencing turbulence in an airplane, being trapped in an elevator, finding out a loved one was involved in an accident, etc.) but most often they are unexpected, occurring for no apparent reason. It is also common for panic attacks to occur in individuals who are suffering with other mental health disorders such as depression or PTSD.
Not everyone who has a panic attack will develop a panic disorder. Panic disorder is when someone has frequent and recurring panic attacks without clear triggers. For a person to be diagnosed with a panic disorder the following DSM-5 criteria must be met:
- The individual must have experienced at least one panic attack followed by one month or more of persistent worry about having more attacks.
- Persistent worry about the consequences of panic attacks.
- Avoidance of places and activities that have become associated with panic attacks or where the individual fears an attack might occur in the future.
- A combination of four or more of the physiological and psychological symptoms described above.
- The attacks are not caused by the effects of a substance (including prescribed medications) or a medical condition.
- The attacks are not better explained as part of another mental health disorder, such as phobias, obsessive-compulsive disorder (OCD), PTSD, or separation anxiety.
Panic disorder is sometimes referred to as “the fear of fear” in that after an initial attack the fear of a recurrence can create a vicious, self-fulfilling cycle. For example, there are times when an initial panic attack is triggered by a random, albeit uncomfortable, physiological event (e.g., a person having trouble breathing while hiking for the first time at a higher altitude where there is less oxygen in the air). Panic attacks can then take on a life of their own as the person fears that it will happen again.
How Common is Panic Disorder and What Are the Causes?
How Common is Panic Disorder and What Are the Causes?A panic disorder can occur at any age, but the mean age of onset is 24. A study conducted by NIMH discovered that 2.3% of teenagers in the United States, aged 13-18, had panic disorder. Additionally, 2.3% of these teens experienced severe difficulties as a result of their panic disorder.
About 2.7% of adults in the U.S. age 18 or older have panic disorder. The percentage is higher for females (3.8%) than for males (1.6%) in the past year. It is estimated that 4.7% of U.S. adults will experience panic disorder at some time in their lives. Of these individuals an estimated 44.8% have serious impairment, 29.5% have moderate impairment, and 25.7% have mild impairment.
As with all mental health disorders, there is no one cause for panic disorder and in any given person there is likely a combination of genetic, biological, and environmental determinants. Anxiety disorders do tend to run in families suggesting the possibility of inherited brain structure, biological, and genetic differences. All babies are born with a specific “temperament” – some are easier to soothe and seemingly without effort learn how to effectively self-regulate. Others are more sensitive, are more easily dysregulated, and take longer to calm down after being stressed. As temperamentally vulnerable children start to engage with the world, they are shaped by their own experience of anxiety and by how the world reacts to them. They begin to develop beliefs about themselves as well, about their self-efficacy and ability to cope with life’s stressors.
Not everything that runs in families is genetically/biologically determined, however. Parents of anxious children who themselves are anxious tend to convey that the world is a dangerous place and to model the avoidance of anxiety-provoking situations. And avoidance is the exact behavior that strengthens rather than diminishes anxiety – hence the phrase, “get back on the horse” to indicate that to reduce anxiety one must “face one’s fears” rather than move away from them. In addition, both anxious and non-anxious parents understandably swoop in to protect vulnerable children and can inadvertently reinforce avoidance, undermining self-confidence as children come to see themselves as ill-equipped to handle stressful situations.
Environmental factors are critically important as well. Sadly, many youngsters are exposed to one or more ACEs, adverse childhood experiences. These include living with a mentally ill or substance abusing parent; physical or emotional neglect; physical, emotional, or sexual abuse; the loss of a parent through death, divorce, or incarceration; exposure to domestic or community violence; exposure to bullying; racism; and extreme poverty and/or homelessness and the insecurity they cause.
Finally, it is important to note that certain medical conditions can mimic or exacerbate anxiety, such as thyroid problems or heart arrhythmia. Using drugs, including prescribed medications and recreational substances, can worsen anxiety and panic. Even caffeine in food can contribute to these feelings..
Effective Treatments Are Available
It is true for many mental health disorders that a combination of psychotherapy and medication is often the most effective. There is considerable evidence that cognitive behavior therapy (CBT) is effective in helping people to lessen both the intensity and frequency of panic episodes. CBT includes examining and challenging one’s thoughts and beliefs; learning to recognize, label, and tolerate uncomfortable or painful emotions; planned exposure techniques to gradually or abruptly force oneself to face a feared situation, place, or object; and the practice of a variety of self-regulation techniques such as meditation, muscle relaxation, breathing techniques, or mindfulness. One variety of CBT, Acceptance and Commitment Therapy (ACT), incorporates mindfulness, accepting without judgment all emotions, and the conscious moving forward toward life goals in spite of anxiety and other uncomfortable emotions. ACT teaches us that rather than waiting for anxiety to lessen or be eliminated, one must get on with one’s life and accept that anxiety and other unpleasant emotions will come along for the ride. Paradoxically, this stance ultimately lessens anxiety and panic episodes.
A variety of psychotropic medications are also available to combine with psychotherapy techniques. Some individuals with severe symptoms may need medications to “take the edge off” before they can concentrate on and effectively engage in CBT techniques. Others who are less paralyzed by anxiety can use both simultaneously, or can initiate psychotherapy alone before considering medication.
Selective serotonin reuptake inhibitors (SSRIs) are classified as antidepressants but are also quite effective at reducing anxiety. They are considered safe and have a low risk of serious side effects and are often the first line of defense in treating panic attacks. Some examples of SSRIs approved by the FDA to treat panic disorder are fluoxetine (Prozac), paroxetine (Paxil, Pexeva), and sertraline (Zoloft). Effexor XR is also approved to treat panic disorder and falls in another class of antidepressants known as SNRIs.
A variety of sedatives known as benzodiazepines are also approved by the FDA to treat anxiety and panic. These include alprazolam (Xanax) and clonazepam (Klonopin). Increasingly, however, medical professionals who prescribe psychoactive medications prefer to start patients on one of the antidepressants mentioned above since benzodiazepines can create mental and/or physical dependence and are therefore more dangerous medications. Such sedatives are sometimes used for brief periods only, or as “PRN” (as needed) medications that can be used occasionally.
How School Professionals and Parents Can Help
There are numerous ways that school professionals and parents can support children and teens who experience panic attacks. As summarized in a Fact Sheet published by KidsHealth last June:
“Teachers can help ease anxiety levels by:
- keeping communications open with the student, parents or guardians, and school counselors and trying to identify triggers that may cause panic attacks
- providing a safe place and a cue system in which the student signals the teacher that a panic attack might be coming, and the student needs to take a time-out
- adjusting the amount of classwork and homework
- encouraging the entire class to use relaxation techniques throughout the day
- encouraging students to exercise regularly, which can help reduce feelings of anxiety in patients with panic disorder”
School districts might also consider administering routine anxiety screening as part of a comprehensive student mental health initiative. A report from October 2022 recommends regular screenings to detect anxiety early and prevent it from worsening or leading to depression. It is important to get screened regularly for anxiety. Early detection can help prevent anxiety from getting worse. If left untreated, anxiety can lead to depression. The study found that no statistically significant harm occurred from screening per se.
Parents can help youngsters cope with anxiety and/or panic attacks in several ways, by:
- Arranging for evaluations with the child’s pediatrician as well as school and/or community based mental health professionals to rule out medical causes and to determine what mental health interventions are recommended.
- Once a diagnosis of anxiety or panic disorder is confirmed, reminding the child frequently that while uncomfortable, the sensations experienced during a panic episode are ultimately harmless.
- Staying in close contact with school professionals to determine possible triggers for anxiety and panic episodes and to collaborate on interventions that can be used both at home and in school (e.g., grounding techniques, breathing exercises, encouraging positive self-talk and threat appraisal, etc.).
- Discouraging avoidance and encouraging preparation: help the child plan ahead for anxiety provoking events or situations as well as for attacks that seem to “come out of the blue” by learning and practicing a number of emotion regulation and cognitive coping strategies.
- Modeling a calm, “can do” approach despite one’s own discomfort while watching your child struggle. Learn how to help your child when they are uncomfortable by asking for support from other adults. This could include your partner, a friend, or a health professional. It is important to also address your own fears and concerns in order to effectively support your child.
Resources:
Psychiatry.org – What are Anxiety Disorders?
Panic attacks and panic disorder – Diagnosis and treatment – Mayo Clinic
Panic Disorder – National Institute of Mental Health (NIMH) (nih.gov)
Anxiety Disorders – National Institute of Mental Health (NIMH) (nih.gov)
Panic Disorder: When Fear Overwhelms – National Institute of Mental Health (NIMH) (nih.gov)
Panic Disorder Fact Sheet (For Schools)
