The panic disorder is characterized by the presence of unforeseen and recurring panic attacks. According to the DSM V, the psychopathology manual of the American Psychiatric Association, and the most widespread today, these attacks are characterized by the sudden onset of a fear of intense discomfort that may last minutes, during which four or more of the following symptoms occur:

  1. Palpitations, pounding heart, or accelerated heart rate.
  2. Sweating.
  3. Trembling or shaking.
  4. Sensation of shortness of breath or smothering.
  5. A feeling of choking.
  6. Chest pain or discomfort.
  7. Nausea or abdominal distress.
  8. Feeling dizzy, unsteady, lightheaded or faint.
  9. Chills or hot flushes.
  10. Paresthesias (numbness or tingling sensation).
  11. Feeling of unreality (derealization) or being detached from oneself (depersonaliaztion).
  12. Fear of losing control or going crazy.
  13. Fear of dying.

On the other hand, also according to this diagnostic manual, at least one of the attacks has been followed by a month over which there has been a concern about the attacks and their consequences (loss of control, fear of going mad or dying) and / or behaviors designed to prevent further panic attacks, such as avoiding certain situations.

Panic disorders can be developed with or without agoraphobia. It will be with agoraphobia when the person suffering from it avoids or fears two or more of the following situations: using public transport, staying in open spaces, staying indoors, queuing or staying in the middle of a crowd, or being out of things. It is common that underlying the situations mentioned there is a great fear of losing control in public.

Panic attacks are often confused with anxiety attacks, but they are really different phenomena, both in their symptoms and their possible cause. In this sense, people who suffer from panic attacks, or who develop a panic disorder experience much more intense discomfort. It can be said that a panic disorder, whether with or without agoraphobia, greatly conditions and limits the life of those who suffer from it, precisely for fear of re-experiencing a panic attack.

The DSM is a great diagnostic manual in terms of the detail with which it exposes the disorders and their symptoms, but unfortunately, it stays in it, and does not delve into their possible causes, greatly limiting their treatment. If we only treat the symptoms, but do not understand the causes of the disorder, the person will develop symptoms again later. Throughout this article, I will detail what I found, based on my clinical experience, and how I treated them.

Since like so many disorders, panic disorder with or without agoraphobia  hugely restrains the lives of those who suffer from it. Therefore, as the treatment starts, we will offer techniques that help stabilize the patient, by decreasing symptoms and helping him to, on the one hand stop suffering from panic attacks, and on the other, to stop avoiding situations where he fears re-experiencing them. That is, the first will be to provide is relaxation techniques that help the patient to lead a life as normal as possible.

At the neurobiological level, the panic circuit begins in the central regions of the middle or midbrain, also called periaqueductal gray, and ascends through middle diencephalic structures, more specifically the dorsomedial thalamus, to the regions of the anterior prosencephalon of the anterior cingulate.

From an Attachment Theory perspective, the panic circuit was initially activated in childhood, when the girl or boy felt separated from the mother. Neurochemistry promoted by separation situations involves decreased opiates and oxytocin, combined with increased glutaminergic impulse.

From an Affective Bond Theory perspective, the panic circuit was initially activated in childhood, when the girl or boy felt separated from the mother. Neurochemistry promoted by separation situations involves decreased opiates and oxytocin, combined with increased glutaminergic impulse.

From my clinical experience, it is also important to address the causes that have led to the development of this type of symptomatology. We will do this at a later time, only when the person is already stabilized and does not experience panic attacks. It’s important to tackle the causes, since ultimately the symptoms of a psychopathological disorder are an expression of a dysfunctional way of relating to one or more situations that cause us discomfort. If we do not address the underlying issue, the symptoms will sooner or later develop again.

Most people who develop this disorder experience circumstances that make it appropriate to review their relationship with their attachment figures. For example, in panic disorder with agoraphobia we often find people who ultimately cannot separate from their parents and face the responsibilities of adult life. In some cases, it is common to experience the loss of a significant attachment figure (a father, a mother, a grandfather …) before developing a panic attack or panic disorder, making it necessary to work out the corresponding grief.

From an Attachment Theory perspective, people who develop panic attacks or panic disorder with or without agoraphobia also have insecure clinging styles in most cases. As for the possible comorbidity of this disorder with others, such as depressive disorder, post-traumatic stress disorder, or others, it is a very complex issue that I have preferred not to go into in this article.

Bibliographic references:

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

Bowlby, J. (1989). Aplicaciones clínicas de una teoría del apego. Barcelona: Paidós Ibérica.

Crittenden, P. M. (1995). Apego y psicopatología. Santiago de Chile: Sociedad de Terapia Cognitiva postracionalista.

Hernández, M. (2017). Apego y psicopatología: la ansiedad y su origen. Conceptualización y tratamiento de las patologías relacionadas con la ansiedad desde una perspectiva integradora. Bilbao: Editorial Desclée de Brower.

Main, M. (2001). Las categorías organizadas del apego en el infante, en el niño, y en el adulto: Atención flexible versus inflexible bajo estrés relacionado con el apego. Aperturas psicoanalíticas8.

Marrone, M., Diamond, N., Juri, L., & Bleichmar, H. (2001). La teoría del apego: un enfoque actual. Madrid: Psimática.

Wallin, D. (2012). El apego en psicoterapia. Bilbao: Editorial Descleé de Brouwer.

The Treatment of Panic Disorder