Q. Discuss the etiology and treatment of panic disorder.

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Biological Factors
1) Genetic factors:
Family and twin studies indicate that panic disorder runs in families. Identical twins seem to have greater possibilities of panic disorder, while concordance is less in fraternal twins. The specific genes responsible for panic disorder are yet to be discovered. However, there seems some evidence that panic disorder and phobia may have some genetic commonness.
2) Brain and biochemical abnormalities: Attempts have been made to associate panic attacks with biochemical characteristics of the brain. It has been observed that exposure to certain biochemicals generate panic attack in those who are already suffering from panic disorder, while this may not have any impact on others. Thus there has been a suggestion that there might be definite
neurobiological differences between the normal persons and those with panic disorder. Some of such substances which may be considered panic provocation agents are sodium lactate, carbon dioxide, caffeine etc.
However, the brain mechanisms associated with the action of these substances are not identical and there have been suggestions that no single neurobiological
mechanism may be held responsible for all types of panic attacks.
Some of the brain mechanisms implicated in panic attack are the increases activity in the hippocampus and locus coeruleus, which are responsible for monitoring external and internal stimuli and moderates brain’s reactions to them. The amygdala is critically important in fear reaction, and is involved in the ‘fear network’ of the brain. Abnormal sensitivity in this region may cause repeated anxiety attacks. Increased noradrenergic activity simulates cardiac problem by enhancing heart rate and breathing problems. It has also been suggested that people with panic disorder may have abnormalities in their benzodiazepine receptors which help in anxiety reduction. The role of GABA neurotransmitter may be important in this respect.

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Psychological Factors
1) Learning factor:
The learning theorists have tried to explain panic attacks as learnt phenomena – specifically as responses to conditioned stimuli. You already know how conditioning occurs and how apparently neutral stimulus may acquire a significance to elicit some response. Take the case of Maya as an instance.
The panic attack happened for her for the first time in the underground train. Subsequently the situation of the train becomes the conditioned stimulus, and Maya is afraid that the next panic attack may also occur in the crowded vehicle. Thus the initial learning is reinforced and increases in vigour by reinforcements in cyclic pattern. This explanation is also known as ‘fear of fear’. Sometimes, an internal stimulus may act as the trigger to panic attack. For example, an increased heart rate may be so associated with panic attack
experiences that if heart rate increases for any reason, panic attack starts. Thus oversensitivity to internal stimuli can also be a cause of panic disorder.
2) Cognitive factors: The cognitive approach to panic attack focuses on the
interpretation of bodily sensations and external cues that may trigger the attack. While the learning approach highlights the oversensitivity to bodily cues, the cognitive approach further affirms that a catastrophic meaning may be assigned to the bodily sensation. For example the racing of the heart may be attributed to a serious malfunctioning of the cardiac system, rather than to the medicine one has taken. If the person is not aware of this catastrophic thought, it may fall within the arena of ‘automatic thoughts’ that non-consciously result in the attack. You may note that the role of interpretation is crucial here. This has been highlighted by experiments where the heart rate has been increased in panic disorder patients by using drugs. If the person knows about the possible effects of the drug, panic attack does not take place or occurs to a much milder degree.

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Panic disorder patients are also known to demonstrate cognitive bias toward certain experiences and symbols. For example they may be more prone to words like ‘fainting’ or ‘shortness of breath’. There is however controversy as to whether these biases have been generated after repeated panic attacks or were already present before the first attack.
However, there seems to be accumulating evidence that a special kind of cognitive orientation is present in some people, which make them more amenable to consider certain stimuli as triggers of panic attack more quickly than others.

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How would you deal with panic disorder? Panic disorder may be treated by
pharmacology or psychotherapy, or a combination of both. Tranquilizers from the Benzodiazepine group of drugs (alprazolam or clonazepam) are often used to handle panic attacks. These however, have the side effect of being addictive. Antidepressants like Tricyclics and SSRIs (Selective Serotonin Reuptake Inhibitors (SSRIs) have also been used with efficacy to deal with panic attacks.

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While these drugs, particularly SSRIs do not have the immediate calming effect like the Benzodiazepine group of drugs, these are relatively free from addiction and have better result in long term treatment. Although extrapyramidal effects like dryness of mouth may be occasional side effects, these are better tolerated by most people also. Psychotherapy is also useful in dealing with panic disorder. You can teach relaxation techniques and breathing exercises to the patient for self management. These techniques include gradually relaxing the muscles of your body, progressively from one extremity to another, and also controlling breathing so that the internal cues of fear are regulated and under control.
Besides you can also employ the Cognitive technique to identify the erroneous automatic thoughts and review them in the light of reality orientation. For example, you may ask the patient to imagine the worst that can happen to her and to judge the probability of its occurrence in real life. You can also ask her to identify the triggering cues and to dissociate them by practice from the immediate physiological responses. It has been suggested that cognitive technique is more helpful than medicine for long term maintenance of the cure in case pf panic disorder.

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